Healthcare Provider Details

I. General information

NPI: 1285506485
Provider Name (Legal Business Name): KATHERINE WILSON LMHC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2025
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 PARK AVE
CRANSTON RI
02910-3227
US

IV. Provider business mailing address

1020 PARK AVE
CRANSTON RI
02910-3227
US

V. Phone/Fax

Practice location:
  • Phone: 401-396-7649
  • Fax: 401-208-2482
Mailing address:
  • Phone: 401-396-7649
  • Fax: 401-208-2482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC00428-A
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: