Healthcare Provider Details

I. General information

NPI: 1255833125
Provider Name (Legal Business Name): ELIZABETH L. WISE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH WISE LCSW, PSYD

II. Dates (important events)

Enumeration Date: 03/06/2018
Last Update Date: 09/17/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 CEDARWOOD DR.
PINE MOUNTAIN CLUB CA
93222-6750
US

IV. Provider business mailing address

PO BOX 6750
PINE MOUNTAIN CLUB CA
93222-6750
US

V. Phone/Fax

Practice location:
  • Phone: 310-422-2047
  • Fax:
Mailing address:
  • Phone: 310-422-2047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number75984
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number99104
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1255833125
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerOTHER
# 2
Identifier75984
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: