Provider Demographics
NPI:1245457761
Name:WILSON, KIMBERLY (LMFT)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2827 SILVERCREST ST
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-3459
Mailing Address - Country:US
Mailing Address - Phone:530-626-5919
Mailing Address - Fax:
Practice Address - Street 1:6692 MERCHANDISE WAY STE B
Practice Address - Street 2:
Practice Address - City:DIAMOND SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95619-9453
Practice Address - Country:US
Practice Address - Phone:530-626-2589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT19855101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health