MEDICARE: BRENDA GAIL WISE LPC

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	101Y00000X	Counselor	PC007958	PA

General Provider Information

NPI Number	:	1558994483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA GAIL WISE LPC

Provider Business Mailing Address
First Line	:	355 BURN HILL RD
Second Line	:
City	:	SHERMANS DALE
State	:	PA
Zip	:	17090-8905
Country	:	US
Telephone Number	:	315-286-6569
Fax Number	:

Provider Business Practice Location Address
First Line	:	355 BURN HILL RD
Second Line	:
City	:	SHERMANS DALE
State	:	PA
Zip	:	17090-8905
Country	:	US
Telephone Number	:	315-286-6569
Fax Number	:

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

Provider Enumeration Date	:	02/19/2020
Last Update Date	:	02/23/2021

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