Provider Demographics
NPI:1881053148
Name:WISE, STEPHANIE (OTD)
Entity type:Individual
Prefix:MISS
First Name:STEPHANIE
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 BRENT DR
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-6057
Mailing Address - Country:US
Mailing Address - Phone:501-920-0804
Mailing Address - Fax:501-771-7648
Practice Address - Street 1:119 W H AVE
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-8733
Practice Address - Country:US
Practice Address - Phone:501-772-3224
Practice Address - Fax:501-771-7648
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist