MEDICARE: ELEANOR RENEE WISE AAS

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

General Provider Information

NPI Number	:	1689869307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELEANOR RENEE WISE AAS

Provider Business Mailing Address
First Line	:	3950 TIMBERLAKE DRIVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115
Country	:	US
Telephone Number	:	919-696-5857
Fax Number	:

Provider Business Practice Location Address
First Line	:	4525 S SANDHILL RD STE 103
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-5955
Country	:	US
Telephone Number	:	702-741-1938
Fax Number	:	702-778-5283

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

Provider Enumeration Date	:	09/06/2007
Last Update Date	:	12/13/2016

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