Provider Demographics
NPI:1700041852
Name:WISE MIND THERAPY SERVICES, LLC
Entity Type:Organization
Organization Name:WISE MIND THERAPY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:MCGONIGLE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:816-822-0200
Mailing Address - Street 1:217 E 63RD ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64113-2224
Mailing Address - Country:US
Mailing Address - Phone:816-822-0200
Mailing Address - Fax:816-444-6425
Practice Address - Street 1:217 E 63RD ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64113-2224
Practice Address - Country:US
Practice Address - Phone:816-822-0200
Practice Address - Fax:816-444-6425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003019074251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000C998Medicare PIN