Provider Demographics
NPI:1386943520
Name:WISE, EMILY NICOLE (MED, LPC)
Entity type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:NICOLE
Last Name:WISE
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13637 SE 94TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73165-4633
Mailing Address - Country:US
Mailing Address - Phone:405-821-6447
Mailing Address - Fax:
Practice Address - Street 1:13637 SE 94TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73165-4633
Practice Address - Country:US
Practice Address - Phone:405-821-6447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-25
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5665101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional