Provider Demographics
NPI:1881966794
Name:WISE, MARY HELEN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:HELEN
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 1:411 W CHAPEL HILL ST
Mailing Address - Street 2:SUITE 908
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-3616
Mailing Address - Country:US
Mailing Address - Phone:919-419-3474
Mailing Address - Fax:919-419-9353
Practice Address - Street 1:411 W CHAPEL HILL ST
Practice Address - Street 2:SUITE 908
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-3616
Practice Address - Country:US
Practice Address - Phone:919-419-3474
Practice Address - Fax:919-419-9353
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0078031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical