Provider Demographics
NPI:1831749555
Name:WISE, SAVANNAH LAUREN
Entity type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:LAUREN
Last Name:WISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 WHITE OAK DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-5853
Mailing Address - Country:US
Mailing Address - Phone:717-919-0312
Mailing Address - Fax:
Practice Address - Street 1:825 WHITE OAK DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-5853
Practice Address - Country:US
Practice Address - Phone:717-919-0312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-14
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11195225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist