Provider Demographics
NPI:1245465558
Name:WISE, DANIEL LYNN (PHD, LP)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:LYNN
Last Name:WISE
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 WILLSON RD STE 205
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55424-1343
Mailing Address - Country:US
Mailing Address - Phone:612-875-4449
Mailing Address - Fax:
Practice Address - Street 1:5200 WILLSON RD STE 205
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55424-1343
Practice Address - Country:US
Practice Address - Phone:612-875-4449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-16
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLP 1925103TC0700X
MO2014023517103TC0700X
MNLP6424103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical