Provider Demographics
NPI:1861978447
Name:WISE, TARYN (PSYD)
Entity type:Individual
Prefix:
First Name:TARYN
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 AUGUSTA AVE
Mailing Address - Street 2:
Mailing Address - City:FT WRIGHT
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3604
Mailing Address - Country:US
Mailing Address - Phone:502-724-2017
Mailing Address - Fax:
Practice Address - Street 1:6900 HOUSTON RD STE 11
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-4891
Practice Address - Country:US
Practice Address - Phone:859-525-4911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY269154103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent