Provider Demographics
NPI:1649248550
Name:WISE, MARY LOUISE (PHD, LP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:WISE
Suffix:
Gender:F
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 1:2 E. FRANKLIN AVE.
Mailing Address - Street 2:#6
Mailing Address - City:MPLS
Mailing Address - State:MN
Mailing Address - Zip Code:55403
Mailing Address - Country:US
Mailing Address - Phone:952-451-8199
Mailing Address - Fax:
Practice Address - Street 1:2 E. FRANKLIN AVE.
Practice Address - Street 2:#6
Practice Address - City:MPLS
Practice Address - State:MN
Practice Address - Zip Code:55403
Practice Address - Country:US
Practice Address - Phone:952-451-8199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2784103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN19356WIOtherBLUE CROSS BLUE SHIELD MN
MN1F233WIOtherBCBS INDIVIDUAL #