Provider Demographics
NPI:1801220579
Name:WILSON, KIMBERLY PATRICE
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:PATRICE
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 1:205 N LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21617-1022
Mailing Address - Country:US
Mailing Address - Phone:410-758-1306
Mailing Address - Fax:410-758-2133
Practice Address - Street 1:205 NORTH LIBERTY ST
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MD
Practice Address - Zip Code:21617
Practice Address - Country:US
Practice Address - Phone:410-758-1306
Practice Address - Fax:410-758-2133
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTRAINEE101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)