Healthcare Provider Details

I. General information

NPI: 1992421705
Provider Name (Legal Business Name): DR. TRACEY WISE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2022
Last Update Date: 10/13/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28-2890 KAPEHU PLACE
PEPEEKEO HI
96783
US

IV. Provider business mailing address

PO BOX 1022
PEPEEKEO HI
96783-1022
US

V. Phone/Fax

Practice location:
  • Phone: 808-895-2593
  • Fax:
Mailing address:
  • Phone: 808-895-2593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1414-08
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC-253
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: