Healthcare Provider Details

I. General information

NPI: 1619225695
Provider Name (Legal Business Name): LAURA ANN KISE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2012
Last Update Date: 03/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 CONCORD RD
YORK PA
17402-8626
US

IV. Provider business mailing address

1803 MOUNT ROSE AVE SUITE B3
YORK PA
17403-3026
US

V. Phone/Fax

Practice location:
  • Phone: 717-851-6340
  • Fax: 717-851-6349
Mailing address:
  • Phone: 717-851-6816
  • Fax: 717-851-6892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS018096
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: