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General NPI Number Information
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NPI Number | 1063661312
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Entity Type | Individual
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Provider Name | RAQUEL MARIE WISE PTA
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Gender | Female
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Dates
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Enumeration Date | 09/11/2008
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Last Update Date | 09/13/2008
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Provider Practice Location Address
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Address Line | 2484 W STATE ST
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City | ALLIANCE
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State | OH
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Zip | 44601-5608
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Country | US
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Telephone | 330-829-2338
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Fax | 330-829-2376
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Provider Business Mailing Address
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Address Line | 4645 BELPAR ST NW
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City | CANTON
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State | OH
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Zip | 44718-3602
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Country | US
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Telephone | 330-493-4210
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Fax | 330-493-4744
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTA - 07048
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License Number State | OH
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