Provider Demographics
NPI:1457478570
Name:WILSON, KRESTA L (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRESTA
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 LEWIS HARGETT CIR # B-100
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3688
Mailing Address - Country:US
Mailing Address - Phone:859-475-4305
Mailing Address - Fax:877-804-4492
Practice Address - Street 1:424 LEWIS HARGETT CIR # B-100
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3688
Practice Address - Country:US
Practice Address - Phone:859-475-4305
Practice Address - Fax:877-804-4492
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY139148235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100315580Medicaid