Healthcare Provider Details

I. General information

NPI: 1245727056
Provider Name (Legal Business Name): MALINDA JEAN WISE MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 05/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 GRANT BLVD W
WABASHA MN
55981
US

IV. Provider business mailing address

1200 GRANT BLVD W
WABASHA MN
55981-1042
US

V. Phone/Fax

Practice location:
  • Phone: 651-565-5600
  • Fax: 651-565-5670
Mailing address:
  • Phone: 651-565-4531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9901
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: