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General NPI Number Information
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NPI Number | 1740408608
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Entity Type | Individual
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Provider Name | KIMBERLY SUE WISE CCC-SLP
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Gender | Female
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Dates
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Enumeration Date | 04/23/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 4692 SPOTTSWOOD AVE
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City | MEMPHIS
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State | TN
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Zip | 38117-4822
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Country | US
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Telephone | 901-647-5682
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Fax | 901-761-7171
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Provider Business Mailing Address
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Address Line | 585 CEDAR GROVE CV
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City | HERNANDO
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State | MS
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Zip | 38632-6656
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Country | US
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Telephone | 901-647-5682
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Fax | 901-761-7171
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 0000001728
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | S2834
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License Number State | MS
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