Provider Demographics
NPI:1942864798
Name:WISE, MICHAEL (MA, RMHCI)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WISE
Suffix:
Gender:M
Credentials:MA, RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12482 CASTLEMAIN TRL
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-8694
Mailing Address - Country:US
Mailing Address - Phone:407-388-5605
Mailing Address - Fax:
Practice Address - Street 1:1150 S SEMORAN BLVD STE A
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-1424
Practice Address - Country:US
Practice Address - Phone:407-704-7811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health