Provider Demographics
NPI:1912260779
Name:WISDOM, NICHOLAS MATTHEW (PHD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:MATTHEW
Last Name:WISDOM
Suffix:
Gender:M
Credentials:PHD
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Mailing Address - Street 1:15222 WOODHORN DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77062-3211
Mailing Address - Country:US
Mailing Address - Phone:405-205-8405
Mailing Address - Fax:
Practice Address - Street 1:1300 BAY AREA BLVD STE B150-15
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-2505
Practice Address - Country:US
Practice Address - Phone:281-954-6828
Practice Address - Fax:346-223-0296
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2021-01-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KS2032103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist