Provider Demographics
NPI:1407839012
Name:WISE, CHRISTY (PSYD)
Entity type:Individual
Prefix:DR
First Name:CHRISTY
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 CAMINO DEL MAR
Mailing Address - Street 2:107
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-2656
Mailing Address - Country:US
Mailing Address - Phone:877-880-7337
Mailing Address - Fax:858-923-1121
Practice Address - Street 1:1104 CAMINO DEL MAR
Practice Address - Street 2:SUITE 107
Practice Address - City:DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92014-2656
Practice Address - Country:US
Practice Address - Phone:877-880-7337
Practice Address - Fax:858-923-1121
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19841103TC0700X, 103TC2200X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11521017OtherCAQH
CADB800ZMedicare UPIN