Provider Demographics
NPI:1902643364
Name:WISE, ATALAYA
Entity type:Individual
Prefix:
First Name:ATALAYA
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6053 E 39TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46226-4901
Mailing Address - Country:US
Mailing Address - Phone:317-557-4550
Mailing Address - Fax:
Practice Address - Street 1:6053 E 39TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-4901
Practice Address - Country:US
Practice Address - Phone:317-557-4550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-12
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty