Provider Demographics
NPI:1760648679
Name:WILSON, KITTY LEIGH
Entity Type:Individual
Prefix:MS
First Name:KITTY
Middle Name:LEIGH
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KITTY
Other - Middle Name:WILSON
Other - Last Name:DOUGLAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3352 N FUTRALL DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4057
Mailing Address - Country:US
Mailing Address - Phone:479-521-5868
Mailing Address - Fax:479-587-8206
Practice Address - Street 1:701 ARKANSAS BLVD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-2105
Practice Address - Country:US
Practice Address - Phone:870-772-5028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-30
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX510311041C0700X
AR2113-M1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical