Provider Demographics
NPI:1316076656
Name:WISE, CHERYL ANNETTE (PHD)
Entity type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:ANNETTE
Last Name:WISE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-2210
Mailing Address - Country:US
Mailing Address - Phone:215-922-7748
Mailing Address - Fax:
Practice Address - Street 1:485 N 3RD ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-2210
Practice Address - Country:US
Practice Address - Phone:215-922-7748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-04
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC003901101YP2500X
PAPS016308103T00000X
WY551103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional