Provider Demographics
NPI:1558670174
Name:WISE, LAUREE (MS,OTR/L)
Entity type:Individual
Prefix:MS
First Name:LAUREE
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:MS,OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 12TH STREET
Mailing Address - Street 2:#3L
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215
Mailing Address - Country:US
Mailing Address - Phone:917-859-3595
Mailing Address - Fax:
Practice Address - Street 1:39 W 14TH ST
Practice Address - Street 2:SUITE 307
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-7489
Practice Address - Country:US
Practice Address - Phone:917-859-3595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010407225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist