Individual
DR. KENNETH F. WISE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PSY.D.
Contact information
Practice address
10300 N CENTRAL EXPY, SUITE 320, DALLAS, TX 75231-8600
(972) 869-7391
(214) 378-7009
Mailing address
529 PARKVIEW LN, RICHARDSON, TX 75080-5116
(972) 869-7391
(972) 235-0121
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
25783
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0042DG
BCBS PROVIDER #
TX
01
—
86564A
BCBS GROUP PROVIDER#
TX
Enumeration date
11/07/2006
Last updated
07/08/2007
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