Provider Demographics
NPI:1518275593
Name:WILSON, KASEY J (MED)
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 EXECUTIVE CENTER DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-8862
Mailing Address - Country:US
Mailing Address - Phone:704-563-4103
Mailing Address - Fax:704-563-4112
Practice Address - Street 1:5701 EXECUTIVE CENTER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8862
Practice Address - Country:US
Practice Address - Phone:704-563-4103
Practice Address - Fax:704-563-4112
Is Sole Proprietor?:No
Enumeration Date:2010-09-23
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11618101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor