Provider Demographics
NPI:1295168912
Name:WISE, TRAWICK SMITH (CCC-SLP)
Entity type:Individual
Prefix:
First Name:TRAWICK
Middle Name:SMITH
Last Name:WISE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:TRAWICK
Other - Middle Name:ASHTON
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2424 DOUBLE CHURCHES RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-2741
Mailing Address - Country:US
Mailing Address - Phone:706-324-6112
Mailing Address - Fax:706-596-8259
Practice Address - Street 1:2424 DOUBLE CHURCHES RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-2741
Practice Address - Country:US
Practice Address - Phone:706-324-6112
Practice Address - Fax:706-596-8259
Is Sole Proprietor?:No
Enumeration Date:2013-08-16
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008285235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist