Healthcare Provider Details

I. General information

NPI: 1124959176
Provider Name (Legal Business Name): CEYLON DEXTER WISE III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2747 AGLER RD
COLUMBUS OH
43224-4615
US

IV. Provider business mailing address

2581 COLTS NECK RD
BLACKLICK OH
43004-9649
US

V. Phone/Fax

Practice location:
  • Phone: 614-402-9122
  • Fax:
Mailing address:
  • Phone: 614-402-9122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: