Provider Demographics
NPI:1104953421
Name:WARDLE, KATHERINE FISKE (PHD)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:FISKE
Last Name:WARDLE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 NOTT ROAD
Mailing Address - Street 2:
Mailing Address - City:REXFORD
Mailing Address - State:NY
Mailing Address - Zip Code:12148-1310
Mailing Address - Country:US
Mailing Address - Phone:518-783-1051
Mailing Address - Fax:518-783-1051
Practice Address - Street 1:70 NOTT ROAD
Practice Address - Street 2:
Practice Address - City:REXFORD
Practice Address - State:NY
Practice Address - Zip Code:12148-1310
Practice Address - Country:US
Practice Address - Phone:518-783-1051
Practice Address - Fax:518-783-1051
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5491103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01587604Medicaid
NYDD5375Medicare ID - Type Unspecified
NY01587604Medicaid