MEDICARE: MS. JANICE WISE LCSW

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	R0256351	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P2527542	OTHER	NY	UNITED HEALTH OXFORD BEH

General Provider Information

NPI Number	:	1629188420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JANICE WISE LCSW

Provider Business Mailing Address
First Line	:	98 BARNYARD LANE
Second Line	:
City	:	ROSLYN HTS
State	:	NY
Zip	:	11577
Country	:	US
Telephone Number	:	516-484-4835
Fax Number	:	516-484-4835

Provider Business Practice Location Address
First Line	:	98 BARNYARD LANE
Second Line	:
City	:	ROSLYN HTS
State	:	NY
Zip	:	11577
Country	:	US
Telephone Number	:	516-484-4835
Fax Number	:	516-484-4835

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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