Provider Demographics
NPI:1093116188
Name:WISE, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 SUN VISTA CT
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-6187
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:MONDOVI
Practice Address - State:WI
Practice Address - Zip Code:54755-1325
Practice Address - Country:US
Practice Address - Phone:715-926-6123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-09
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4660-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant