Healthcare Provider Details

I. General information

NPI: 1235316159
Provider Name (Legal Business Name): KIMBERLY M WILSON NMD,LPC,LMFT, LCDC,L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 01/09/2024
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2942 N 24TH ST #114-545
PHOENIX AZ
85016
US

IV. Provider business mailing address

712 MASON DR VIRTUAL SERVICES ONLY
ALLEN TX
75013
US

V. Phone/Fax

Practice location:
  • Phone: 888-539-1233
  • Fax: 469-606-9102
Mailing address:
  • Phone: 888-539-1233
  • Fax: 469-606-9102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15525
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number84153
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number203984
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number071039
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number071039
License Number StateAZ
# 8
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMI3923
License Number StateTX
# 10
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateTX
# 12
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number07-1039
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: