Provider Demographics
NPI:1609003565
Name:WISE, BRIAN SCOTT
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:SCOTT
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 1:1936 CARLOTTA DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94519-1358
Mailing Address - Country:US
Mailing Address - Phone:925-682-7474
Mailing Address - Fax:
Practice Address - Street 1:1026 OAK GROVE RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94518-3289
Practice Address - Country:US
Practice Address - Phone:925-682-7474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84632106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist