Basic Information
| Provider Information | |||||||||
| NPI: | 1982604401 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WISE-VANDERLEE | ||||||||
| FirstName: | NANCY | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2412 S CLIFF AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571054031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053224079 | ||||||||
| FaxNumber: | 6053224080 | ||||||||
| Practice Location | |||||||||
| Address1: | 2412 S CLIFF AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571054031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053224079 | ||||||||
| FaxNumber: | 6053224080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2005 | ||||||||
| LastUpdateDate: | 11/20/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 378 | SD | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 22161 | 01 | SD | SIOUX VALLEY HEALTH PLAN | OTHER | 6551333 | 05 | SD | MEDICAID |