Provider Demographics
NPI:1477645471
Name:WISE, MARK (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:WISE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4989 POST ROAD PASS
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30088-2007
Mailing Address - Country:US
Mailing Address - Phone:770-469-6754
Mailing Address - Fax:770-498-4738
Practice Address - Street 1:3000 SCHATULGA RD BLDG 5
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-3117
Practice Address - Country:US
Practice Address - Phone:706-568-5216
Practice Address - Fax:706-562-1484
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY000818103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical