Provider Demographics
NPI:1164201810
Name:WILSON, KRISTA JULIANE (TCADC)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:JULIANE
Last Name:WILSON
Suffix:
Gender:F
Credentials:TCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-9188
Mailing Address - Country:US
Mailing Address - Phone:270-259-4652
Mailing Address - Fax:
Practice Address - Street 1:805 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-9188
Practice Address - Country:US
Practice Address - Phone:270-259-4652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY287527101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)