Healthcare Provider Details

I. General information

NPI: 1821621749
Provider Name (Legal Business Name): KIM WILSON, MSW, LCSW, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2020
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3447 ROBINHOOD RD
WINSTON SALEM NC
27106-4701
US

IV. Provider business mailing address

655 N SPRING ST
WINSTON SALEM NC
27101-1326
US

V. Phone/Fax

Practice location:
  • Phone: 419-450-2033
  • Fax:
Mailing address:
  • Phone: 419-450-2033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIM WILSON
Title or Position: LCSW
Credential: MSW, LCSW
Phone: 419-450-2033