Provider Demographics
NPI:1851071955
Name:WILSON, ASHLEY MB (MA/LPA)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MB
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA/LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 BROADWAY ST STE A
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-0738
Mailing Address - Country:US
Mailing Address - Phone:630-615-0605
Mailing Address - Fax:
Practice Address - Street 1:413 BROADWAY ST STE A
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-0738
Practice Address - Country:US
Practice Address - Phone:270-217-5218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY273301103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist