Healthcare Provider Details

I. General information

NPI: 1124904065
Provider Name (Legal Business Name): MARY LORRAINE WISE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BEN WISE

II. Dates (important events)

Enumeration Date: 08/14/2025
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 LONG BEACH BLVD
LONG BEACH CA
90807-5062
US

IV. Provider business mailing address

3210 LONG BEACH BLVD
LONG BEACH CA
90807-5062
US

V. Phone/Fax

Practice location:
  • Phone: 562-548-6500
  • Fax:
Mailing address:
  • Phone: 562-548-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: