MEDICARE: WISE MIND COUNSELING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor
2	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1295500338
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISE MIND COUNSELING

Provider Business Mailing Address
First Line	:	1465 KELLY JOHNSON BLVD STE 350
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-3983
Country	:	US
Telephone Number	:	719-209-1376
Fax Number	:

Provider Business Practice Location Address
First Line	:	1465 KELLY JOHNSON BLVD STE 350
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-3983
Country	:	US
Telephone Number	:	719-209-1376
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KARISSA WIGHT
Credential	:	LMFT
Telephone Number	:	719-209-1376

Provider Enumeration Date	:	11/20/2023
Last Update Date	:	11/20/2023

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Directions to “WISE MIND COUNSELING ” Practice Location

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