Provider Demographics
NPI:1669853388
Name:WISDOM, KRISTY (BCBA)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:WISDOM
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21600 OXNARD ST
Mailing Address - Street 2:SUITE 1800
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-4976
Mailing Address - Country:US
Mailing Address - Phone:818-345-2345
Mailing Address - Fax:818-449-0994
Practice Address - Street 1:9390 RESEARCH BLVD
Practice Address - Street 2:BUILDING 1 #100
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-6585
Practice Address - Country:US
Practice Address - Phone:512-330-9520
Practice Address - Fax:512-330-9505
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-15-18121103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst