Healthcare Provider Details

I. General information

NPI: 1992974026
Provider Name (Legal Business Name): ELIZABETH WISE OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2008
Last Update Date: 03/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 9TH AVE BOX 359819
SEATTLE WA
98104-2420
US

IV. Provider business mailing address

325 9TH AVE BOX 359819
SEATTLE WA
98104-2420
US

V. Phone/Fax

Practice location:
  • Phone: 206-744-5909
  • Fax:
Mailing address:
  • Phone: 206-744-5909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberTL10000815
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License NumberTL10000815
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberTL10000815
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: