Provider Demographics
NPI:1679005581
Name:WISE, LICIA (LMFT)
Entity Type:Individual
Prefix:
First Name:LICIA
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 E 3RD ST
Mailing Address - Street 2:APT. 24
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-3677
Mailing Address - Country:US
Mailing Address - Phone:310-919-6815
Mailing Address - Fax:
Practice Address - Street 1:21151 S WESTERN AVE STE 255
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-1724
Practice Address - Country:US
Practice Address - Phone:310-919-6815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90769106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist