Provider Demographics
NPI:1619041696
Name:WISE, HOLLY H (PT)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:H
Last Name:WISE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 BROUGHTON RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-7529
Mailing Address - Country:US
Mailing Address - Phone:843-442-7632
Mailing Address - Fax:
Practice Address - Street 1:615 WESLEY DR
Practice Address - Street 2:SUITE 110
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-7204
Practice Address - Country:US
Practice Address - Phone:843-768-5455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC407225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC426536Medicare ID - Type Unspecified