Provider Demographics
NPI:1346594017
Name:WILSON, KATHY MO (MS, MFTI, LADCI)
Entity Type:Individual
Prefix:MS
First Name:KATHY
Middle Name:MO
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, MFTI, LADCI
Other - Prefix:MS
Other - First Name:KAT
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, MFTI, LADCI
Mailing Address - Street 1:PO BOX 1782
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89432-1782
Mailing Address - Country:US
Mailing Address - Phone:775-240-1796
Mailing Address - Fax:775-355-7116
Practice Address - Street 1:550 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-1450
Practice Address - Country:US
Practice Address - Phone:775-355-7722
Practice Address - Fax:775-355-7116
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-02
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLC-I 00043101YA0400X
NVMI0312106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)