Provider Demographics
NPI:1407449770
Name:WISE, SHAWNA MARIE
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:MARIE
Last Name:WISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8308 OHIO RIVER RD STE B
Mailing Address - Street 2:
Mailing Address - City:WHEELERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45694-1713
Mailing Address - Country:US
Mailing Address - Phone:740-529-1201
Mailing Address - Fax:740-876-8854
Practice Address - Street 1:8308 OHIO RIVER RD STE B
Practice Address - Street 2:
Practice Address - City:WHEELERSBURG
Practice Address - State:OH
Practice Address - Zip Code:45694-1713
Practice Address - Country:US
Practice Address - Phone:740-529-8328
Practice Address - Fax:740-876-8854
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-17
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH175T00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty