Provider Demographics
NPI:1972028132
Name:WISE, CASEY LAYNE
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:LAYNE
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 1:1044 N NARCISSUS AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-1468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1044 N NARCISSUS AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-1468
Practice Address - Country:US
Practice Address - Phone:918-505-8209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-09
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)