Provider Demographics
NPI:1922267210
Name:WISE, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WISE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 N LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MANISTIQUE
Mailing Address - State:MI
Mailing Address - Zip Code:49854-1234
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:114 W ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:SAINT IGNACE
Practice Address - State:MI
Practice Address - Zip Code:49781-1868
Practice Address - Country:US
Practice Address - Phone:906-643-8616
Practice Address - Fax:906-643-7194
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional