Provider Demographics
NPI:1023340643
Name:WISE, KENNA MARIE (LPC)
Entity type:Individual
Prefix:MRS
First Name:KENNA
Middle Name:MARIE
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 1:110 E FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096-5156
Mailing Address - Country:US
Mailing Address - Phone:580-373-7609
Mailing Address - Fax:
Practice Address - Street 1:2250 W MODELLE AVE
Practice Address - Street 2:A & B
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-3749
Practice Address - Country:US
Practice Address - Phone:580-383-7609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-06
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3631101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional