Provider Demographics
NPI:1114270451
Name:WISEHART, KATHERINE SUE (MAC)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:SUE
Last Name:WISEHART
Suffix:
Gender:F
Credentials:MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22110 STATE HIGHWAY 6
Mailing Address - Street 2:
Mailing Address - City:EWING
Mailing Address - State:MO
Mailing Address - Zip Code:63440-2629
Mailing Address - Country:US
Mailing Address - Phone:573-767-1212
Mailing Address - Fax:573-767-1212
Practice Address - Street 1:105 EAST LAFAYETTE
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MO
Practice Address - Zip Code:63457
Practice Address - Country:US
Practice Address - Phone:573-767-1212
Practice Address - Fax:573-767-1212
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-24
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor