Provider Demographics
NPI:1083290126
Name:WISEMAN, KAYLE A (CTRS)
Entity Type:Individual
Prefix:
First Name:KAYLE
Middle Name:A
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N FRONT ST STE 15
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:NE
Mailing Address - Zip Code:68069-2250
Mailing Address - Country:US
Mailing Address - Phone:402-669-3197
Mailing Address - Fax:
Practice Address - Street 1:800 N FRONT ST STE 15
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NE
Practice Address - Zip Code:68069-2250
Practice Address - Country:US
Practice Address - Phone:402-669-3197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE81878225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist