Healthcare Provider Details

I. General information

NPI: 1356426381
Provider Name (Legal Business Name): KRISTIN LEEAN WILSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 09/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S JOHNSTONE AVE SUITE 503
BARTLESVILLE OK
74003-6622
US

IV. Provider business mailing address

501 S JOHNSTONE AVE SUITE 503
BARTLESVILLE OK
74003-6622
US

V. Phone/Fax

Practice location:
  • Phone: 918-337-6050
  • Fax: 918-337-6061
Mailing address:
  • Phone: 918-337-6050
  • Fax: 918-337-6061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3199
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: