Provider Demographics
NPI:1760726970
Name:WILSON, KATRINA K D (MA, TLLP, LLPC)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:K D
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, TLLP, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4625 BECKLEY RD
Mailing Address - Street 2:BUILDING 300
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-7948
Mailing Address - Country:US
Mailing Address - Phone:269-979-8119
Mailing Address - Fax:269-979-8124
Practice Address - Street 1:4625 BECKLEY RD
Practice Address - Street 2:BUILDING 300
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-7948
Practice Address - Country:US
Practice Address - Phone:269-979-8119
Practice Address - Fax:269-979-8124
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013299101YP2500X
MI6301015310103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional