Provider Demographics
NPI:1073800108
Name:WISE, KELLY JEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:WISE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 PLAZA ST E
Mailing Address - Street 2:1G
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-5025
Mailing Address - Country:US
Mailing Address - Phone:917-822-5045
Mailing Address - Fax:
Practice Address - Street 1:60 PLAZA ST E
Practice Address - Street 2:SUITE 1G
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-5025
Practice Address - Country:US
Practice Address - Phone:917-822-5045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-10
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY73-076991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical