Provider Demographics
NPI:1366198889
Name:WISE, KATHERINE
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
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 1:1726 KINGSLEY AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4411
Mailing Address - Country:US
Mailing Address - Phone:904-278-5644
Mailing Address - Fax:
Practice Address - Street 1:1726 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4463
Practice Address - Country:US
Practice Address - Phone:904-278-5644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH20132101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health