Healthcare Provider Details

I. General information

NPI: 1629260344
Provider Name (Legal Business Name): KENNETH D WILSON LMHCA, CDP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 01/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 NIPSIC AVE
BREMERTON WA
98310-4837
US

IV. Provider business mailing address

915 NIPSIC AVE
BREMERTON WA
98310-4837
US

V. Phone/Fax

Practice location:
  • Phone: 405-863-4396
  • Fax:
Mailing address:
  • Phone: 405-863-4396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60361555
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC60694550
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: