Provider Demographics
NPI:1760540082
Name:WISE, DEBORAH LYNN (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:LYNN
Last Name:WISE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10222 S 48TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-1228
Mailing Address - Country:US
Mailing Address - Phone:480-235-2277
Mailing Address - Fax:
Practice Address - Street 1:3100 W RAY RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-2470
Practice Address - Country:US
Practice Address - Phone:480-207-5975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0046235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00500223OtherASHA CERTIFICATION #
AZ0046OtherAZ. SPEECH PATHOLOGY LICENSE
AZ824137Medicaid