Provider Demographics
NPI:1154569556
Name:WISE, CAROLYN DENISE (RRW)
Entity type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:DENISE
Last Name:WISE
Suffix:
Gender:F
Credentials:RRW
Other - Prefix:
Other - First Name:NONE
Other - Middle Name:NONE
Other - Last Name:NONE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RRW
Mailing Address - Street 1:1446 ETHAN WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-2214
Mailing Address - Country:US
Mailing Address - Phone:916-922-5110
Mailing Address - Fax:916-921-1239
Practice Address - Street 1:1446 ETHAN WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2214
Practice Address - Country:US
Practice Address - Phone:916-922-5110
Practice Address - Fax:916-921-1239
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-23
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator