Provider Demographics
NPI:1932744919
Name:WISE, CHERYL L
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:L
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 1:3200 CRESTBROOK CT
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-8142
Mailing Address - Country:US
Mailing Address - Phone:502-773-8483
Mailing Address - Fax:
Practice Address - Street 1:3200 CRESTBROOK CT
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-8142
Practice Address - Country:US
Practice Address - Phone:502-773-8483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-13
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY283787106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist