Healthcare Provider Details

I. General information

NPI: 1831798438
Provider Name (Legal Business Name): MARIA LYNN WISE LCDCIII
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6527 COLERAIN AVE
CINCINNATI OH
45239-5537
US

IV. Provider business mailing address

615 ELSINORE PL STE 200
CINCINNATI OH
45202-1459
US

V. Phone/Fax

Practice location:
  • Phone: 833-510-4357
  • Fax:
Mailing address:
  • Phone: 513-834-7063
  • Fax: 513-873-1567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCIII.162111
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number162111
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: