Provider Demographics
NPI:1912581414
Name:WISE, DESMON (LMSW)
Entity Type:Individual
Prefix:MR
First Name:DESMON
Middle Name:
Last Name:WISE
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 MAIN ST APT C3
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-2944
Mailing Address - Country:US
Mailing Address - Phone:860-656-5491
Mailing Address - Fax:
Practice Address - Street 1:2553 WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3021
Practice Address - Country:US
Practice Address - Phone:203-584-7971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT47491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical