Provider Demographics
NPI:1639576200
Name:WILSON, KATHLEEN (RN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757-1748
Mailing Address - Country:US
Mailing Address - Phone:508-422-8095
Mailing Address - Fax:508-478-0843
Practice Address - Street 1:32 HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-1748
Practice Address - Country:US
Practice Address - Phone:508-422-8095
Practice Address - Fax:508-478-0843
Is Sole Proprietor?:No
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2264579101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health