Provider Demographics
NPI:1912353715
Name:WISE, SUSAN (LPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 OLD BALLAS RD.
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141
Mailing Address - Country:US
Mailing Address - Phone:314-569-2253
Mailing Address - Fax:314-569-2280
Practice Address - Street 1:711 OLD BALLAS RD.
Practice Address - Street 2:SUITE 203
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-569-2253
Practice Address - Fax:314-569-2280
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000510101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor