MEDICARE: KIMBERLY WISLON MSCP, LPC, LSOTP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	17628	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6199LC	OTHER		BCBS

General Provider Information

NPI Number	:	1497938195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY WISLON MSCP, LPC, LSOTP

Provider Business Mailing Address
First Line	:	10221 DESERT SANDS ST
Second Line	:	SUITE 211
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-3959
Country	:	US
Telephone Number	:	210-834-7762
Fax Number	:	210-349-2273

Provider Business Practice Location Address
First Line	:	10221 DESERT SANDS ST
Second Line	:	SUITE 211
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-3959
Country	:	US
Telephone Number	:	210-834-7762
Fax Number	:	210-349-2273

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/17/2007
Last Update Date	:	12/17/2007

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Directions to “ KIMBERLY WISLON MSCP, LPC, LSOTP” Practice Location

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