Provider Demographics
NPI:1386894137
Name:WISE-BROWN, DEIRDRE ELAINE (MS)
Entity type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:ELAINE
Last Name:WISE-BROWN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:995 HYDE PARK AVE
Mailing Address - Street 2:APT # 1
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-3161
Mailing Address - Country:US
Mailing Address - Phone:617-331-4169
Mailing Address - Fax:
Practice Address - Street 1:180 CENTRE ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-2733
Practice Address - Country:US
Practice Address - Phone:508-586-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)