Provider Demographics
NPI:1093105850
Name:WISE, KIMBERLY KATHLEEN (MA, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:KATHLEEN
Last Name:WISE
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:KATHLEEN
Other - Last Name:TASKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:902 S CORONA ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-4412
Mailing Address - Country:US
Mailing Address - Phone:720-839-8901
Mailing Address - Fax:
Practice Address - Street 1:1440 BLAKE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80202-1474
Practice Address - Country:US
Practice Address - Phone:720-839-8901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11886101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional