Provider Demographics
NPI:1164901757
Name:WISE, KELLI-ANN
Entity Type:Individual
Prefix:
First Name:KELLI-ANN
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 1:65 CIRCLE AVE
Mailing Address - Street 2:
Mailing Address - City:LARCHMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10538-4125
Mailing Address - Country:US
Mailing Address - Phone:917-370-8686
Mailing Address - Fax:
Practice Address - Street 1:65 CIRCLE AVE
Practice Address - Street 2:
Practice Address - City:LARCHMONT
Practice Address - State:NY
Practice Address - Zip Code:10538-4125
Practice Address - Country:US
Practice Address - Phone:917-370-8686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist