Healthcare Provider Details

I. General information

NPI: 1417612383
Provider Name (Legal Business Name): EDWARD LOWELL WISE III MA, QMHS-3
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2021
Last Update Date: 11/04/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3099 SULLIVANT AVE STE H
COLUMBUS OH
43204-1800
US

IV. Provider business mailing address

3099 SULLIVANT AVE STE H
COLUMBUS OH
43204-1800
US

V. Phone/Fax

Practice location:
  • Phone: 614-371-2303
  • Fax: 800-905-9950
Mailing address:
  • Phone: 614-371-2303
  • Fax: 800-905-9950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: