Provider Demographics
NPI:1700955275
Name:WISE, KENNETH F (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:F
Last Name:WISE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 PARKVIEW LN
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-5116
Mailing Address - Country:US
Mailing Address - Phone:972-869-7391
Mailing Address - Fax:972-235-0121
Practice Address - Street 1:10300 N CENTRAL EXPY
Practice Address - Street 2:SUITE 320
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-8600
Practice Address - Country:US
Practice Address - Phone:972-869-7391
Practice Address - Fax:214-378-7009
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25783103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86564AOtherBCBS GROUP PROVIDER#
TX0042DGOtherBCBS PROVIDER #