Provider Demographics
NPI:1033904230
Name:WISE, ELISE
Entity type:Individual
Prefix:
First Name:ELISE
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 1:761 PARK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CROZET
Mailing Address - State:VA
Mailing Address - Zip Code:22932-3266
Mailing Address - Country:US
Mailing Address - Phone:434-996-0475
Mailing Address - Fax:
Practice Address - Street 1:1 BOARS HEAD PL STE 230
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-4628
Practice Address - Country:US
Practice Address - Phone:434-996-0475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-10
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704017797101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor