Healthcare Provider Details

I. General information

NPI: 1700955275
Provider Name (Legal Business Name): KENNETH F. WISE PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10300 N CENTRAL EXPY SUITE 320
DALLAS TX
75231-8600
US

IV. Provider business mailing address

529 PARKVIEW LN
RICHARDSON TX
75080-5116
US

V. Phone/Fax

Practice location:
  • Phone: 972-869-7391
  • Fax: 214-378-7009
Mailing address:
  • Phone: 972-869-7391
  • Fax: 972-235-0121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number25783
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: