Provider Demographics
NPI:1255791802
Name:WISE-GASTINELL, KIM A (ADD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:A
Last Name:WISE-GASTINELL
Suffix:
Gender:F
Credentials:ADD
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:A
Other - Last Name:WISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:422 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-6505
Mailing Address - Country:US
Mailing Address - Phone:225-922-0478
Mailing Address - Fax:888-965-7288
Practice Address - Street 1:5635 TARRYTOWN AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-3535
Practice Address - Country:US
Practice Address - Phone:225-476-3809
Practice Address - Fax:225-256-2668
Is Sole Proprietor?:No
Enumeration Date:2016-02-24
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPLC9874103TC1900X
101Y00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPLC9874Medicaid