Basic Information
| Provider Information | |||||||||
| NPI: | 1730543927 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WISE | ||||||||
| FirstName: | RHONDA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1328 2ND STREET | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103925855 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6666 GREEN VALLEY CIR | ||||||||
| Address2: | |||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902307068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103058878 | ||||||||
| FaxNumber: | 3108465278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2016 | ||||||||
| LastUpdateDate: | 08/30/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.