Provider Demographics
NPI:1649328022
Name:WISE-ANDREWS, EDITH ELIZABETH (RTC)
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:ELIZABETH
Last Name:WISE-ANDREWS
Suffix:
Gender:F
Credentials:RTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 MCCLURE SUBDIVISION RD
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-6113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:860 N BUSH ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-3919
Practice Address - Country:US
Practice Address - Phone:707-463-4303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA2660-T225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered171M00000XOther Service ProvidersCase Manager/Care Coordinator
Not Answered225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2660-TOtherRECREATION THERAPY CERTIF