Provider Demographics
NPI:1083036701
Name:WILSON, KIMBERLY (LICSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:D'NAE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:6210 BELCREST RD APT 1228
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-2967
Mailing Address - Country:US
Mailing Address - Phone:718-877-0633
Mailing Address - Fax:
Practice Address - Street 1:6210 BELCREST RD APT 1228
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-2967
Practice Address - Country:US
Practice Address - Phone:718-877-0633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500795051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical