MEDICARE: WISE SELF, LLC

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1538986575
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISE SELF, LLC

Provider Business Mailing Address
First Line	:	110 LAFAYETTE ST
Second Line	:
City	:	PAWTUCKET
State	:	RI
Zip	:	02860-6012
Country	:	US
Telephone Number	:	401-263-3999
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 LAFAYETTE ST
Second Line	:
City	:	PAWTUCKET
State	:	RI
Zip	:	02860-6012
Country	:	US
Telephone Number	:	401-263-3999
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MEREDITH SINEL
Credential	:	LICSW
Telephone Number	:	401-263-3399

Provider Enumeration Date	:	09/23/2024
Last Update Date	:	09/23/2024

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