Healthcare Provider Details

I. General information

NPI: 1457318594
Provider Name (Legal Business Name): KATIE ANNE WISE M.ED,LPCC,
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US 1909 US 1909
BARBOURVILLE KY
40906-4090
US

IV. Provider business mailing address

21 KEENELAND TRL
CORBIN KY
40701-8544
US

V. Phone/Fax

Practice location:
  • Phone: 606-546-3805
  • Fax: 606-546-3903
Mailing address:
  • Phone: 937-869-2932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number103975
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: