Healthcare Provider Details

I. General information

NPI: 1255791802
Provider Name (Legal Business Name): KIM A WISE-GASTINELL AD.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIM A WISE

II. Dates (important events)

Enumeration Date: 02/24/2016
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5635 TARRYTOWN AVE
BATON ROUGE LA
70808-3535
US

IV. Provider business mailing address

422 COLONIAL DR
BATON ROUGE LA
70806-6505
US

V. Phone/Fax

Practice location:
  • Phone: 225-476-3809
  • Fax: 225-256-2668
Mailing address:
  • Phone: 225-922-0478
  • Fax: 888-965-7288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPLC9874
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: