Provider Demographics
NPI:1609096346
Name:WISE, RICHARD ALLEN (PHD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALLEN
Last Name:WISE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 S COLUMBIA RD
Mailing Address - Street 2:#202
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-772-1588
Mailing Address - Fax:701-746-6077
Practice Address - Street 1:2100 S COLUMBIA RD
Practice Address - Street 2:#202
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201
Practice Address - Country:US
Practice Address - Phone:701-772-1588
Practice Address - Fax:701-746-6077
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND390103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
27835OtherBCND