Provider Demographics
NPI:1932643624
Name:WISEMAN, KANDRA RAE (MA BCBA BHP)
Entity Type:Individual
Prefix:
First Name:KANDRA
Middle Name:RAE
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:MA BCBA BHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1848 N 52ND ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-3402
Mailing Address - Country:US
Mailing Address - Phone:602-510-5401
Mailing Address - Fax:
Practice Address - Street 1:1830 S ALMA SCHOOL RD STE 130
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-3088
Practice Address - Country:US
Practice Address - Phone:602-510-5401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBA-0258103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst