Provider Demographics
NPI:1265587430
Name:WILSON, KIMBERLY LANNETTE (LMFT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LANNETTE
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 1:15105D JOHN J DELANEY DR STE 192
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-2741
Mailing Address - Country:US
Mailing Address - Phone:704-769-0660
Mailing Address - Fax:800-858-2194
Practice Address - Street 1:2015 AYRSLEY TOWN BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-4067
Practice Address - Country:US
Practice Address - Phone:704-280-8502
Practice Address - Fax:800-858-2194
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN785106H00000X
MI4101006188106H00000X
GAMFT000954106H00000X
NC1303106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA090073276AMedicaid