Provider Demographics
NPI:1033322094
Name:WILSON, KATHERINE K (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:K
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10236
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85271-0236
Mailing Address - Country:US
Mailing Address - Phone:480-966-8729
Mailing Address - Fax:480-446-0854
Practice Address - Street 1:2101 E BROADWAY RD
Practice Address - Street 2:SUITE 33
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-1879
Practice Address - Country:US
Practice Address - Phone:480-966-8729
Practice Address - Fax:480-446-0854
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0870103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8886088816OtherMEDICARE PROVIDER ENROLLM
AZS11639Medicare UPIN
AZZPHD870Medicare ID - Type Unspecified