Provider Demographics
NPI:1942597711
Name:WISE, MARILYN M (LICDC)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:M
Last Name:WISE
Suffix:
Gender:F
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25901 EMERY RD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-5774
Mailing Address - Country:US
Mailing Address - Phone:440-622-8782
Mailing Address - Fax:216-765-4470
Practice Address - Street 1:25901 EMERY RD
Practice Address - Street 2:SUITE 114
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-5774
Practice Address - Country:US
Practice Address - Phone:440-622-8782
Practice Address - Fax:216-765-4470
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH933446101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)