Healthcare Provider Details

I. General information

NPI: 1225185119
Provider Name (Legal Business Name): KATIE ELIZABETH WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 11/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL DIV PSYCHIATRY, CHILD AND ADOLESCENT
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

4511 FOREST PARK AVE STE 4300
SAINT LOUIS MO
63108-2138
US

V. Phone/Fax

Practice location:
  • Phone: 314-286-1700
  • Fax: 314-286-1777
Mailing address:
  • Phone: 314-286-1700
  • Fax: 314-408-2756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2011040150
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: