Provider Demographics
NPI:1235316159
Name:WILSON, KIMBERLY M (NMD,LPC,LMFT, LCDC,L)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:NMD,LPC,LMFT, LCDC,L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 MASON DR
Mailing Address - Street 2:VIRTUAL SERVICES ONLY
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013
Mailing Address - Country:US
Mailing Address - Phone:888-539-1233
Mailing Address - Fax:469-606-9102
Practice Address - Street 1:2942 N 24TH ST
Practice Address - Street 2:#114-545
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016
Practice Address - Country:US
Practice Address - Phone:888-539-1233
Practice Address - Fax:469-606-9102
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15525101YA0400X
TX84153101YM0800X
TX203984106H00000X
AZ071039133N00000X, 175L00000X
174H00000X, 174N00000X, 176B00000X, 374J00000X
TXMI3923225700000X
TX376K00000X
AZ07-1039175F00000X, 175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No174H00000XOther Service ProvidersHealth Educator
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No175L00000XOther Service ProvidersHomeopath
No176B00000XOther Service ProvidersMidwife
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No374J00000XNursing Service Related ProvidersDoula
No376K00000XNursing Service Related ProvidersNurse's Aide