Provider Demographics
NPI:1023608353
Name:WISE, DANIEL RAYMOND (COTA)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:RAYMOND
Last Name:WISE
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-6906
Mailing Address - Country:US
Mailing Address - Phone:603-369-7133
Mailing Address - Fax:
Practice Address - Street 1:66 NORTH RD
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:NH
Practice Address - Zip Code:03037-1306
Practice Address - Country:US
Practice Address - Phone:603-463-7422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0822224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant