Provider Demographics
NPI:1275267668
Name:WISE, KENDAL BROOKE
Entity Type:Individual
Prefix:
First Name:KENDAL
Middle Name:BROOKE
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:PO BOX 170776
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-0034
Mailing Address - Country:US
Mailing Address - Phone:971-666-5675
Mailing Address - Fax:833-485-5167
Practice Address - Street 1:10109 LAKE CREEK PKWY # 170776
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78729-1711
Practice Address - Country:US
Practice Address - Phone:971-666-5675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
TX1-23-65346103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician