Provider Demographics
NPI:1992201412
Name:WISE, ANNA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:
Other - Last Name:MCKISSACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5012 WENONAH DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75209-4833
Mailing Address - Country:US
Mailing Address - Phone:662-574-3861
Mailing Address - Fax:
Practice Address - Street 1:5012 WENONAH DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75209-4833
Practice Address - Country:US
Practice Address - Phone:662-574-3861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112574235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist