Provider Demographics
NPI:1871360727
Name:WISE, MARK STEPHEN
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEPHEN
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 1:2501 E PIEDMONT RD STE 202
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-7758
Mailing Address - Country:US
Mailing Address - Phone:470-435-1547
Mailing Address - Fax:
Practice Address - Street 1:2501 E PIEDMONT RD STE 202
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-7758
Practice Address - Country:US
Practice Address - Phone:470-435-1547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC014257102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst