Provider Demographics
NPI:1457732752
Name:WISE, SCOTT (CADC II)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:
Last Name:WISE
Suffix:
Gender:M
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 N HIGHWAY 101
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WARRENTON
Mailing Address - State:OR
Mailing Address - Zip Code:97146-9371
Mailing Address - Country:US
Mailing Address - Phone:503-325-5722
Mailing Address - Fax:
Practice Address - Street 1:65 N HIGHWAY 101
Practice Address - Street 2:SUITE 204
Practice Address - City:WARRENTON
Practice Address - State:OR
Practice Address - Zip Code:97146-9371
Practice Address - Country:US
Practice Address - Phone:503-325-5722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR99-07-36101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)