Provider Demographics
NPI:1588402390
Name:WISE, CHRISTIAN LLOYD SAMUEL
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:LLOYD SAMUEL
Last Name:WISE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 JOSEPH PATH
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5298
Mailing Address - Country:US
Mailing Address - Phone:713-503-0123
Mailing Address - Fax:
Practice Address - Street 1:201 N BROAD ST STE 200
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-3569
Practice Address - Country:US
Practice Address - Phone:507-225-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical