Provider Demographics
NPI:1851952964
Name:WISE-SMITH, VICKI LOU
Entity Type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:LOU
Last Name:WISE-SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 W 13TH ST
Mailing Address - Street 2:
Mailing Address - City:FRONT ROYAL
Mailing Address - State:VA
Mailing Address - Zip Code:22630-2912
Mailing Address - Country:US
Mailing Address - Phone:540-535-6196
Mailing Address - Fax:
Practice Address - Street 1:500 PEGASUS CT STE 500
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22602-4596
Practice Address - Country:US
Practice Address - Phone:540-313-4196
Practice Address - Fax:540-686-7906
Is Sole Proprietor?:No
Enumeration Date:2019-06-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710103350101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)