Healthcare Provider Details

I. General information

NPI: 1619098266
Provider Name (Legal Business Name): JOANNE MIZII WISELY SPEECH-LANGUAGE PATH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

IV. Provider business mailing address

118 DEEPDALE RD
WAYNE PA
19087-2628
US

V. Phone/Fax

Practice location:
  • Phone: 610-925-4380
  • Fax: 610-925-4441
Mailing address:
  • Phone: 610-688-7609
  • Fax: 610-925-4441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSL002176L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: