Provider Demographics
NPI:1760003958
Name:WILSON, KIMBERLY JOY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JOY
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11192 SE 52ND CT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97222-3500
Mailing Address - Country:US
Mailing Address - Phone:503-850-8088
Mailing Address - Fax:
Practice Address - Street 1:11105 NE 14TH ST STE 103
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-4309
Practice Address - Country:US
Practice Address - Phone:503-850-8088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-29
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR7572101YM0800X
WAMC61308406101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health