MEDICARE: DR. BRIAN KEITH WISE PH.D., LPC-S, NCC

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	101YP2500X	Professional Counselor	0017202	CO

General Provider Information

NPI Number	:	1952436701
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN KEITH WISE PH.D., LPC-S, NCC

Provider Business Mailing Address
First Line	:	5775 CHASE POINT CIR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-3589
Country	:	US
Telephone Number	:	197-318-3022
Fax Number	:

Provider Business Practice Location Address
First Line	:	5775 CHASE POINT CIR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-3589
Country	:	US
Telephone Number	:	719-318-3022
Fax Number	:

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

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	10/12/2023

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