Provider Demographics
NPI:1659777597
Name:WISE, JANET
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4760 SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-4820
Mailing Address - Country:US
Mailing Address - Phone:310-390-6612
Mailing Address - Fax:
Practice Address - Street 1:11133 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-3918
Practice Address - Country:US
Practice Address - Phone:310-895-2312
Practice Address - Fax:310-895-2353
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARAS-W0706161054101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)