Provider Demographics
NPI:1134959521
Name:WISE, COOPER HUDSON (MA, AMFT)
Entity type:Individual
Prefix:
First Name:COOPER
Middle Name:HUDSON
Last Name:WISE
Suffix:
Gender:M
Credentials:MA, AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24077 STATE HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-8519
Mailing Address - Country:US
Mailing Address - Phone:530-559-3905
Mailing Address - Fax:
Practice Address - Street 1:24077 STATE HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-8519
Practice Address - Country:US
Practice Address - Phone:530-559-3905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA147304106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist