MEDICARE: ELLA RAYNE WISELY

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1225894355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLA RAYNE WISELY

Provider Business Mailing Address
First Line	:	1220 CONCORD AVE STE 185
Second Line	:
City	:	CONCORD
State	:	CA
Zip	:	94520-4906
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1220 CONCORD AVE STE 185
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525
Country	:	US
Telephone Number	:	210-307-8855
Fax Number	:

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

Provider Enumeration Date	:	02/26/2024
Last Update Date	:	05/07/2026

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Directions to “ ELLA RAYNE WISELY ” Practice Location

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