Provider Demographics
NPI:1184250979
Name:WISDOM, LARA M
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:M
Last Name:WISDOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8818 GOLDEN LN
Mailing Address - Street 2:
Mailing Address - City:DE SOTO
Mailing Address - State:KS
Mailing Address - Zip Code:66018-7501
Mailing Address - Country:US
Mailing Address - Phone:615-571-3982
Mailing Address - Fax:
Practice Address - Street 1:11900 W 87TH STREET PKWY STE 130
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66215-4517
Practice Address - Country:US
Practice Address - Phone:615-571-3982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-12
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020037121101YP2500X
KS3527101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty