Provider Demographics
NPI:1982604401
Name:WISE-VANDERLEE, NANCY (PHD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:WISE-VANDERLEE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2412 S CLIFF AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-4031
Mailing Address - Country:US
Mailing Address - Phone:605-322-4079
Mailing Address - Fax:605-322-4080
Practice Address - Street 1:2412 S CLIFF AVE STE 200
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-4031
Practice Address - Country:US
Practice Address - Phone:605-322-4079
Practice Address - Fax:605-322-4080
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD378103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD22161OtherSIOUX VALLEY HEALTH PLAN
SD6551333Medicaid
SD22161OtherSIOUX VALLEY HEALTH PLAN
S39637Medicare UPIN