Provider Demographics
NPI:1639934334
Name:WILSON, KRISTEN (LCSW-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 LOCKHART MOUNTAIN RD UNIT 63
Mailing Address - Street 2:
Mailing Address - City:LAKE GEORGE
Mailing Address - State:NY
Mailing Address - Zip Code:12845-4985
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6901 N CHARLES ST BLDG E
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-3780
Practice Address - Country:US
Practice Address - Phone:443-809-4130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2062031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical