Provider Demographics
NPI:1689869307
Name:WISE, ELEANOR RENEE (AAS)
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:RENEE
Last Name:WISE
Suffix:
Gender:F
Credentials:AAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 TIMBERLAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89115
Mailing Address - Country:US
Mailing Address - Phone:919-696-5857
Mailing Address - Fax:
Practice Address - Street 1:4525 S SANDHILL RD STE 103
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5955
Practice Address - Country:US
Practice Address - Phone:702-741-1938
Practice Address - Fax:702-778-5283
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor