Provider Demographics
NPI:1700246709
Name:WILSON, KIMBERLY MOSS (LCSW, CAADC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MOSS
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW, CAADC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:DIANE
Other - Last Name:MOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:3921 KENSINGTON DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-2535
Mailing Address - Country:US
Mailing Address - Phone:404-936-1431
Mailing Address - Fax:
Practice Address - Street 1:1116 E PONCE DE LEON AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2711
Practice Address - Country:US
Practice Address - Phone:404-377-7669
Practice Address - Fax:404-377-8536
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-03
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAC0159101YA0400X
GACSW0055731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)