Provider Demographics
NPI:1720865256
Name:WISE, TEGAN (MA)
Entity Type:Individual
Prefix:
First Name:TEGAN
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 E CONESTOGA RD
Mailing Address - Street 2:
Mailing Address - City:ELVERSON
Mailing Address - State:PA
Mailing Address - Zip Code:19520-9413
Mailing Address - Country:US
Mailing Address - Phone:610-608-9747
Mailing Address - Fax:
Practice Address - Street 1:23 E CONESTOGA RD
Practice Address - Street 2:
Practice Address - City:ELVERSON
Practice Address - State:PA
Practice Address - Zip Code:19520-9413
Practice Address - Country:US
Practice Address - Phone:610-608-9747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)