Provider Demographics
NPI:1740408608
Name:WISE, KIMBERLY SUE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:WISE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 CEDAR GROVE CV
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-6656
Mailing Address - Country:US
Mailing Address - Phone:901-647-5682
Mailing Address - Fax:901-761-7171
Practice Address - Street 1:4692 SPOTTSWOOD AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4822
Practice Address - Country:US
Practice Address - Phone:901-647-5682
Practice Address - Fax:901-761-7171
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000001728235Z00000X
MSS2834235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist