Provider Demographics
NPI:1609155225
Name:WISE, DONNA (COTA)
Entity Type:Individual
Prefix:MS
First Name:DONNA
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:
Other - Last Name:VAUGHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5200 TOWN AND COUNTRY BLVD APT 1410
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-6897
Mailing Address - Country:US
Mailing Address - Phone:806-678-8207
Mailing Address - Fax:
Practice Address - Street 1:2300 POOL RD
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-4254
Practice Address - Country:US
Practice Address - Phone:877-852-6376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX208327224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant