MEDICARE: MS. ELIZABETH WISE CCC/SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	2202004050	VA

General Provider Information

NPI Number	:	1003131723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELIZABETH WISE CCC/SLP

Provider Business Mailing Address
First Line	:	4102 E PARHAM RD
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23228-2743
Country	:	US
Telephone Number	:	804-672-8588
Fax Number	:	804-672-8587

Provider Business Practice Location Address
First Line	:	4102 E PARHAM RD
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23228-2743
Country	:	US
Telephone Number	:	804-672-8588
Fax Number	:	804-672-8587

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2010
Last Update Date	:	04/06/2010

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