MEDICARE: WISE THERAPY LCSW PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1447916390
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISE THERAPY LCSW PC

Provider Business Mailing Address
First Line	:	60 PLAZA ST E APT 1G
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11238-5030
Country	:	US
Telephone Number	:	917-727-0522
Fax Number	:

Provider Business Practice Location Address
First Line	:	60 PLAZA ST E # BS-1
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11238-5025
Country	:	US
Telephone Number	:	917-822-5045
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. KELLY WISE
Credential	:	LCSW-R,PHD,CST/CSTS
Telephone Number	:	917-727-0522

Provider Enumeration Date	:	11/15/2021
Last Update Date	:	11/15/2021

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