Provider Demographics
NPI:1598483703
Name:WISE, XOE A (LSW)
Entity Type:Individual
Prefix:MISS
First Name:XOE
Middle Name:A
Last Name:WISE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 N SHERIDAN RD APT 1406
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-4846
Mailing Address - Country:US
Mailing Address - Phone:872-216-7222
Mailing Address - Fax:
Practice Address - Street 1:1700 W IRVING PARK RD STE 104
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2596
Practice Address - Country:US
Practice Address - Phone:872-216-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1501086791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical