Provider Demographics
NPI:1942467899
Name:WISE, MICHELLE MARIE (LPC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:WISE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:M
Other - Last Name:WOJSIAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2104 ZIMMERLY RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-6213
Mailing Address - Country:US
Mailing Address - Phone:814-547-8170
Mailing Address - Fax:
Practice Address - Street 1:2104 ZIMMERLY RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-6213
Practice Address - Country:US
Practice Address - Phone:814-547-8170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC004652101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102643049Medicaid