Healthcare Provider Details

I. General information

NPI: 1871581017
Provider Name (Legal Business Name): KATHLEEN MARIE WISE M.A., L.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 07/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 BASS LAKE RD SUITE 106
NEW HOPE MN
55428-3860
US

IV. Provider business mailing address

205 LILY POND CIR
LORETTO MN
55357-9654
US

V. Phone/Fax

Practice location:
  • Phone: 612-865-9143
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP3227
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: