Healthcare Provider Details

I. General information

NPI: 1770181638
Provider Name (Legal Business Name): WISE FUTURE GROUP SUPPORT SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2020
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10244 E COLONIAL DR STE 110
ORLANDO FL
32817-4365
US

IV. Provider business mailing address

2307 GREENWILLOW DR
ORLANDO FL
32825-7572
US

V. Phone/Fax

Practice location:
  • Phone: 407-202-9440
  • Fax: 407-203-4710
Mailing address:
  • Phone: 407-508-7374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: YAZNELLY S RIVERA
Title or Position: CEO
Credential: MPA, MSCJ, CBHCMS
Phone: 407-508-7374