Provider Demographics
NPI:1720689722
Name:WISE, KELLY (BCBA, LBA)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 WINDSOR PATH STE 1
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-9819
Mailing Address - Country:US
Mailing Address - Phone:203-885-8293
Mailing Address - Fax:
Practice Address - Street 1:105 WINDSOR PATH STE 1
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9819
Practice Address - Country:US
Practice Address - Phone:203-885-8293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-20-45730103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst