Provider Demographics
NPI:1609420371
Name:WISE, ROBERT GRAHAM JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GRAHAM
Last Name:WISE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10417 RIVERSIDE DR APT C
Mailing Address - Street 2:
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602-2466
Mailing Address - Country:US
Mailing Address - Phone:323-377-0874
Mailing Address - Fax:
Practice Address - Street 1:10417 RIVERSIDE DR APT C
Practice Address - Street 2:
Practice Address - City:TOLUCA LAKE
Practice Address - State:CA
Practice Address - Zip Code:91602-2466
Practice Address - Country:US
Practice Address - Phone:323-377-0874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA645732717101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor