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General NPI Number Information
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NPI Number | 1912581414
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Entity Type | Individual
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Provider Name | DESMON WISE LMSW
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Gender | Male
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Dates
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Enumeration Date | 05/11/2021
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Last Update Date | 05/11/2021
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Provider Practice Location Address
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Address Line | 2553 WHITNEY AVE
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City | HAMDEN
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State | CT
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Zip | 06518-3021
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Country | US
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Telephone | 203-584-7971
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Fax |
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Provider Business Mailing Address
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Address Line | 281 MAIN ST APT C3
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City | FARMINGTON
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State | CT
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Zip | 06032-2944
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Country | US
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Telephone | 860-656-5491
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 4749
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License Number State | CT
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