Provider Demographics
NPI:1497938195
Name:WISLON, KIMBERLY (MSCP, LPC, LSOTP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WISLON
Suffix:
Gender:F
Credentials:MSCP, LPC, LSOTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10221 DESERT SANDS ST
Mailing Address - Street 2:SUITE 211
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-3959
Mailing Address - Country:US
Mailing Address - Phone:210-834-7762
Mailing Address - Fax:210-349-2273
Practice Address - Street 1:10221 DESERT SANDS ST
Practice Address - Street 2:SUITE 211
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-3959
Practice Address - Country:US
Practice Address - Phone:210-834-7762
Practice Address - Fax:210-349-2273
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17628103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
6199LCOtherBCBS