Healthcare Provider Details

I. General information

NPI: 1326968280
Provider Name (Legal Business Name): TANESHA WISE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

478 HENRY DR SW
MARIETTA GA
30064-3400
US

IV. Provider business mailing address

478 HENRY DR SW
MARIETTA GA
30064-3400
US

V. Phone/Fax

Practice location:
  • Phone: 678-558-9095
  • Fax:
Mailing address:
  • Phone: 678-558-9095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number050542707
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: