Provider Demographics
NPI:1699515379
Name:WISE, IRENE CRISTINA (LP)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:CRISTINA
Last Name:WISE
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:WA
Mailing Address - Zip Code:98231-0069
Mailing Address - Country:US
Mailing Address - Phone:425-321-1242
Mailing Address - Fax:888-972-9442
Practice Address - Street 1:288 MARTIN ST STE 100
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:WA
Practice Address - Zip Code:98230-4045
Practice Address - Country:US
Practice Address - Phone:360-594-0767
Practice Address - Fax:888-972-9442
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-29
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY31119103TC0700X
WAPY61549569103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical