Provider Demographics
NPI:1710863725
Name:WISE, KRISTINE M
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:M
Last Name:WISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 CARDINAL DR STE 280
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-6598
Mailing Address - Country:US
Mailing Address - Phone:847-214-0078
Mailing Address - Fax:
Practice Address - Street 1:300 CARDINAL DR STE 280
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-6598
Practice Address - Country:US
Practice Address - Phone:847-214-0078
Practice Address - Fax:331-269-2106
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-14
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150115930324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility