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General NPI Number Information
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NPI Number | 1679005581
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Entity Type | Individual
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Provider Name | LICIA WISE LMFT
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Gender | Female
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Dates
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Enumeration Date | 03/30/2017
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Last Update Date | 11/21/2018
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Provider Practice Location Address
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Address Line | 21151 S WESTERN AVE STE 255
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City | TORRANCE
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State | CA
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Zip | 90501-1724
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Country | US
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Telephone | 310-919-6815
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Fax |
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Provider Business Mailing Address
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Address Line | 1302 E 3RD ST APT. 24
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City | LONG BEACH
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State | CA
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Zip | 90802-3677
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Country | US
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Telephone | 310-919-6815
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Fax |
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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 | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 90769
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License Number State | CA
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