=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245335561
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERESA N WISE PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2006
-----------------------------------------------------
Last Update Date | 04/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13200 STRICKLAND RD STE 114297
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27613-5212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-395-9618
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13200 STRICKLAND RD STE 114297
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27613-5212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-395-9618
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 3084
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------