Provider Demographics
NPI:1700210887
Name:WISE, REBECCA LEIGH (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:LEIGH
Last Name:WISE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8212 WOLVERINE DR NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-5268
Mailing Address - Country:US
Mailing Address - Phone:505-450-6932
Mailing Address - Fax:
Practice Address - Street 1:4477 9TH AVE NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-5634
Practice Address - Country:US
Practice Address - Phone:505-892-7735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4766235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist