Provider Demographics
NPI:1205476983
Name:WISE, PAMELA SUE (LPC,CPC)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:SUE
Last Name:WISE
Suffix:
Gender:F
Credentials:LPC,CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4385 OAKES MILL CT
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80109-7985
Mailing Address - Country:US
Mailing Address - Phone:580-445-8643
Mailing Address - Fax:
Practice Address - Street 1:4385 OAKES MILL CT
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80109-7985
Practice Address - Country:US
Practice Address - Phone:580-445-8643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1205101Y00000X
NVCP0221101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
04291953OtherBIRTHDATE