Provider Demographics
NPI:1578830675
Name:WISE, TERESA D (PT)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:D
Last Name:WISE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4317 BRADFORD DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-2427
Mailing Address - Country:US
Mailing Address - Phone:843-331-7666
Mailing Address - Fax:
Practice Address - Street 1:4317 BRADFORD DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-2427
Practice Address - Country:US
Practice Address - Phone:843-331-7666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-18
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4366225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist