Provider Demographics
NPI:1699239475
Name:LOUISE WISE LLC
Entity type:Organization
Organization Name:LOUISE WISE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:LOUISE
Authorized Official - Middle Name:
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-831-6429
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021-0309
Mailing Address - Country:US
Mailing Address - Phone:678-368-5561
Mailing Address - Fax:
Practice Address - Street 1:2206 HANFRED LN STE 103
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4809
Practice Address - Country:US
Practice Address - Phone:678-831-6429
Practice Address - Fax:687-668-2848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-26
Last Update Date:2023-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)