Provider Demographics
NPI:1528418308
Name:WISE, KIRSTEN J (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:J
Last Name:WISE
Suffix:
Gender:F
Credentials:MS CCC-SLP
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Mailing Address - Street 1:884 QUAIL RUN RD UNIT C
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-8277
Mailing Address - Country:US
Mailing Address - Phone:307-899-3479
Mailing Address - Fax:
Practice Address - Street 1:1039 STONERIDGE DR STE 5
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-7056
Practice Address - Country:US
Practice Address - Phone:406-624-6599
Practice Address - Fax:888-336-0944
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-13
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MTSLP-SP-LIC-5850235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist