1093105850 NPI number — KIMBERLY KATHLEEN WISE MA, LPC, NCC

Table of content: BARBARA SUZANNE BRANDVOLD PT (NPI 1891031100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093105850 NPI number — KIMBERLY KATHLEEN WISE MA, LPC, NCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WISE
Provider First Name:
KIMBERLY
Provider Middle Name:
KATHLEEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LPC, NCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TASKEY
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
KATHLEEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093105850
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
902 S CORONA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80209-4412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-839-8901
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1440 BLAKE ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80202-1474
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-839-8901
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/02/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  11886 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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