Healthcare Provider Details

I. General information

NPI: 1609177559
Provider Name (Legal Business Name): KRISTEN A WILSON PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2010
Last Update Date: 04/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7315 DIXIE HWY
FLORENCE KY
41042-2126
US

IV. Provider business mailing address

7315 DIXIE HWY
FLORENCE KY
41042-2126
US

V. Phone/Fax

Practice location:
  • Phone: 859-282-0119
  • Fax: 859-282-8018
Mailing address:
  • Phone: 859-282-0119
  • Fax: 859-282-8018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1723
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6925
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1723
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number1723
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number1723
License Number StateKY
# 6
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number1723
License Number StateKY
# 7
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number1723
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: