Provider Demographics
NPI:1447811468
Name:WISE, VONETTA (CDCA II)
Entity type:Individual
Prefix:
First Name:VONETTA
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:CDCA II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3330
Mailing Address - Country:US
Mailing Address - Phone:859-360-0205
Mailing Address - Fax:
Practice Address - Street 1:47 E HOLLISTER ST STE 102
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-1840
Practice Address - Country:US
Practice Address - Phone:513-258-0318
Practice Address - Fax:513-258-0318
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH170540101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)