Provider Demographics
NPI:1598255481
Name:WYSE, KIMBERLY KAY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:KAY
Last Name:WYSE
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 1:2520 S UNIVERSITY PARK DRIVE
Mailing Address - Street 2:BUILDING D CAAT CENTER
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48859
Mailing Address - Country:US
Mailing Address - Phone:989-774-2529
Mailing Address - Fax:
Practice Address - Street 1:2520 S UNIVERSITY PARK DRIVE
Practice Address - Street 2:BUILDING D CAAT CENTER
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48859
Practice Address - Country:US
Practice Address - Phone:989-774-2529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISP0000000823583103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool