Provider Demographics
NPI:1629520978
Name:WISE, MICHELLE M (LPC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:WISE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 S IH 35
Mailing Address - Street 2:SUITE 210
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-8931
Mailing Address - Country:US
Mailing Address - Phone:512-343-8606
Mailing Address - Fax:512-343-8620
Practice Address - Street 1:1524 S IH 35
Practice Address - Street 2:SUITE 210
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-8931
Practice Address - Country:US
Practice Address - Phone:512-343-8606
Practice Address - Fax:512-343-8620
Is Sole Proprietor?:No
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11597101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional