Provider Demographics
NPI:1902419161
Name:WILSON, KRISTEN (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:MATTHEWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:518 THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-3016
Mailing Address - Country:US
Mailing Address - Phone:734-787-3802
Mailing Address - Fax:
Practice Address - Street 1:39325 PLYMOUTH RD STE 202
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-4531
Practice Address - Country:US
Practice Address - Phone:734-787-3802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-27
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401222505101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401222505OtherLLPC