Provider Demographics
NPI:1609270545
Name:WISE, SANDRA ROBINSON (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:ROBINSON
Last Name:WISE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 LOWELL CIR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-2216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2615 LOWELL CIR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2216
Practice Address - Country:US
Practice Address - Phone:321-749-0216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 5491103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical