Provider Demographics
NPI:1225436777
Name:WISE, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
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 1:670 W WAYMAN ST APT 1905
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-1703
Mailing Address - Country:US
Mailing Address - Phone:352-216-4820
Mailing Address - Fax:
Practice Address - Street 1:670 W WAYMAN ST APT 1905
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661-1703
Practice Address - Country:US
Practice Address - Phone:352-216-4820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 6888235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist