Healthcare Provider Details

I. General information

NPI: 1740408608
Provider Name (Legal Business Name): KIMBERLY SUE WISE CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4692 SPOTTSWOOD AVE
MEMPHIS TN
38117-4822
US

IV. Provider business mailing address

585 CEDAR GROVE CV
HERNANDO MS
38632-6656
US

V. Phone/Fax

Practice location:
  • Phone: 901-647-5682
  • Fax: 901-761-7171
Mailing address:
  • Phone: 901-647-5682
  • Fax: 901-761-7171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number0000001728
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberS2834
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: