Provider Demographics
NPI:1457478570
Name:WILSON, KRESTA L (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:KRESTA
Middle Name:L
Last Name:WILSON
Suffix:
Gender:
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 TIFFANIE CT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40514-4082
Mailing Address - Country:US
Mailing Address - Phone:859-806-5717
Mailing Address - Fax:859-208-8980
Practice Address - Street 1:825 TIFFANIE CT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40514-4082
Practice Address - Country:US
Practice Address - Phone:859-806-5717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
KY139148235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100315580Medicaid