Provider Demographics
NPI:1700571288
Name:WISE, KAYLIN PAIGE
Entity Type:Individual
Prefix:
First Name:KAYLIN
Middle Name:PAIGE
Last Name:WISE
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 1:1331 SUMMERS PL UNIT C
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604-4441
Mailing Address - Country:US
Mailing Address - Phone:580-576-0267
Mailing Address - Fax:
Practice Address - Street 1:2020 WILLOW RUN
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-1421
Practice Address - Country:US
Practice Address - Phone:580-823-8017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRBT-23-267112106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician