Provider Demographics
NPI:1154645877
Name:WILDES, KIMBERLY ANN (DRPH, MA, LPC-I)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ANN
Last Name:WILDES
Suffix:
Gender:F
Credentials:DRPH, MA, LPC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1458 CAMPBELL RD
Mailing Address - Street 2:STE 250A
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77055-4669
Mailing Address - Country:US
Mailing Address - Phone:281-896-1194
Mailing Address - Fax:
Practice Address - Street 1:1458 CAMPBELL RD
Practice Address - Street 2:STE 250A
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77055-4669
Practice Address - Country:US
Practice Address - Phone:281-896-1194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64208101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional