Provider Demographics
NPI:1538225891
Name:WISE, JULIE (MS, LCPC, NCC)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:MS, LCPC, NCC
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 336
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:ID
Mailing Address - Zip Code:83239-0336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:164 S 5TH ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:ID
Practice Address - Zip Code:83254-1557
Practice Address - Country:US
Practice Address - Phone:208-847-4464
Practice Address - Fax:208-847-0980
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC3325101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8C493OtherBLUE CROSS LCPC