Provider Demographics
NPI:1285180679
Name:WISE, KIMBERLY (CATC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:CATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4227 BAY ST APT 328
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-4243
Mailing Address - Country:US
Mailing Address - Phone:510-487-2910
Mailing Address - Fax:510-487-2916
Practice Address - Street 1:682 BRIERGATE WAY
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94544-7245
Practice Address - Country:US
Practice Address - Phone:510-487-2910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1684731101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)