=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932721479
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINDSEY DANIELLE WISE M.S., CCC/SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2020
-----------------------------------------------------
Last Update Date | 05/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21214 NORTHWEST FWY
-----------------------------------------------------
City | CYPRESS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77429-3373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-635-7448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10611 LONESOME DOVE TRL
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77095-7056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-635-7448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 106913
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------