Provider Demographics
NPI:1194139980
Name:WISE, BRADLEY G (LICDC-CS)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:G
Last Name:WISE
Suffix:
Gender:M
Credentials:LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 788
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44901-0788
Mailing Address - Country:US
Mailing Address - Phone:419-526-2000
Mailing Address - Fax:419-524-8022
Practice Address - Street 1:1150 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-9718
Practice Address - Country:US
Practice Address - Phone:419-526-2000
Practice Address - Fax:419-524-8022
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH954172101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)