Provider Demographics
NPI:1629260344
Name:WILSON, KENNETH D (LMHCA, CDP)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:D
Last Name:WILSON
Suffix:
Gender:M
Credentials:LMHCA, CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 NIPSIC AVE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-4837
Mailing Address - Country:US
Mailing Address - Phone:405-863-4396
Mailing Address - Fax:
Practice Address - Street 1:915 NIPSIC AVE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-4837
Practice Address - Country:US
Practice Address - Phone:405-863-4396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60694550101YM0800X
WACP60361555101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)