Provider Demographics
NPI:1710172820
Name:WISE, PANDORA (LMSW)
Entity Type:Individual
Prefix:
First Name:PANDORA
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 SAINT NICHOLAS PL APT 41
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-1263
Mailing Address - Country:US
Mailing Address - Phone:212-368-7942
Mailing Address - Fax:
Practice Address - Street 1:3600 JEROME AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-1052
Practice Address - Country:US
Practice Address - Phone:718-881-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072581-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker