Provider Demographics
NPI:1770181638
Name:WISE FUTURE GROUP SUPPORT SERVICES, LLC
Entity Type:Organization
Organization Name:WISE FUTURE GROUP SUPPORT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:YAZNELLY
Authorized Official - Middle Name:S
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MPA, MSCJ, CBHCMS
Authorized Official - Phone:407-508-7374
Mailing Address - Street 1:2307 GREENWILLOW DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-7572
Mailing Address - Country:US
Mailing Address - Phone:407-508-7374
Mailing Address - Fax:
Practice Address - Street 1:10244 E COLONIAL DR STE 110
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-4365
Practice Address - Country:US
Practice Address - Phone:407-202-9440
Practice Address - Fax:407-203-4710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-13
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016554600Medicaid
FL101284000Medicaid
FL110237900Medicaid
FL019545700Medicaid
FL110561900Medicaid
FL110159900Medicaid