Provider Demographics
NPI:1821563735
Name:WILSON, KENNETH LAMAR (LPC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LAMAR
Last Name:WILSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 IRWINTON RD APT 6
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-3886
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2245 VINEVILLE AVE STE B
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-3115
Practice Address - Country:US
Practice Address - Phone:478-288-0709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-06
Last Update Date:2022-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006444101YP2500X
GALPC012032101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional