Healthcare Provider Details

I. General information

NPI: 1891243887
Provider Name (Legal Business Name): KATHERINE WISEHART
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2016
Last Update Date: 08/07/2021
Certification Date: 08/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 STARGAZER DR
SMITH RIVER CA
95567-9390
US

IV. Provider business mailing address

185 STARGAZER DR
SMITH RIVER CA
95567-9390
US

V. Phone/Fax

Practice location:
  • Phone: 386-576-6894
  • Fax:
Mailing address:
  • Phone: 386-576-6894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number214170
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number363662
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: