Provider Demographics
NPI:1871581017
Name:WISE, KATHLEEN MARIE (MA, LP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:WISE
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 LILY POND CIR
Mailing Address - Street 2:
Mailing Address - City:LORETTO
Mailing Address - State:MN
Mailing Address - Zip Code:55357-9654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7600 BASS LAKE RD
Practice Address - Street 2:SUITE 106
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-3860
Practice Address - Country:US
Practice Address - Phone:612-865-9143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3227103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN500526400Medicaid
620000287Medicare ID - Type Unspecified