Provider Demographics
NPI:1619225695
Name:KISE, LAURA ANN (PHD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:KISE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1803 MOUNT ROSE AVE
Mailing Address - Street 2:SUITE B3
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17403-3026
Mailing Address - Country:US
Mailing Address - Phone:717-851-6816
Mailing Address - Fax:717-851-6892
Practice Address - Street 1:3550 CONCORD RD
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-8626
Practice Address - Country:US
Practice Address - Phone:717-851-6340
Practice Address - Fax:717-851-6349
Is Sole Proprietor?:No
Enumeration Date:2012-08-22
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS018096103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103225203Medicaid