Provider Demographics
NPI:1700074739
Name:WILSON, RITA RAE (PHD)
Entity Type:Individual
Prefix:DR
First Name:RITA
Middle Name:RAE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 TROOST AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64109-1538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2901 TROOST AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64109-1538
Practice Address - Country:US
Practice Address - Phone:816-418-7034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-03
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0298196103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO856276407Medicaid