Provider Demographics
NPI:1194177428
Name:WISE, CARLY D (MS, ED S)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:D
Last Name:WISE
Suffix:
Gender:F
Credentials:MS, ED S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 MAIN STREET
Mailing Address - Street 2:PO BOX 421
Mailing Address - City:CLAYSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:119 MAIN ST
Practice Address - Street 2:
Practice Address - City:CLAYSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15323-2396
Practice Address - Country:US
Practice Address - Phone:724-665-5364
Practice Address - Fax:724-663-3696
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2539197103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool