Provider Demographics
NPI:1003167743
Name:WILSON, KENT A (PSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 W 26TH AVE STE 10-C
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-5308
Mailing Address - Country:US
Mailing Address - Phone:303-234-1026
Mailing Address - Fax:303-758-7798
Practice Address - Street 1:2460 W 26TH AVE STE 10-C
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-5308
Practice Address - Country:US
Practice Address - Phone:303-234-1026
Practice Address - Fax:303-758-7798
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1119103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist