Provider Demographics
NPI:1225185119
Name:WILSON, KATIE ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:ELIZABETH
Last Name:WILSON
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Gender:F
Credentials:MD
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Mailing Address - Street 1:4511 FOREST PARK AVE
Mailing Address - Street 2:STE 4300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2138
Mailing Address - Country:US
Mailing Address - Phone:314-286-1700
Mailing Address - Fax:314-408-2756
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:DIV PSYCHIATRY, CHILD AND ADOLESCENT
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-286-1700
Practice Address - Fax:314-286-1777
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2021-11-15
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Provider Licenses
StateLicense IDTaxonomies
MO20110401502084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207172503Medicaid