Provider Demographics
NPI:1932577277
Name:WISE, LAURA KAY (LPC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:KAY
Last Name:WISE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1036 RIDGEVIEW DRIVE APT 2D
Mailing Address - Street 2:
Mailing Address - City:MADILL
Mailing Address - State:OK
Mailing Address - Zip Code:73446
Mailing Address - Country:US
Mailing Address - Phone:580-263-8882
Mailing Address - Fax:
Practice Address - Street 1:717 B HWY E
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:OK
Practice Address - Zip Code:73439
Practice Address - Country:US
Practice Address - Phone:580-564-7308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-03
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OKLPC07504101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health