Provider Demographics
NPI:1285153833
Name:WISE, LETITIA (PTA)
Entity type:Individual
Prefix:
First Name:LETITIA
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:PTA
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 5034
Mailing Address - Street 2:
Mailing Address - City:KINGSHILL
Mailing Address - State:VI
Mailing Address - Zip Code:00851-5034
Mailing Address - Country:US
Mailing Address - Phone:340-473-1688
Mailing Address - Fax:
Practice Address - Street 1:2455 OAK GROVE CHURCH RD
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-9513
Practice Address - Country:US
Practice Address - Phone:770-834-1737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-14
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001912225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty