=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346594017
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHY M.O. WILSON MS, MFTI, LADCI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2012
-----------------------------------------------------
Last Update Date | 11/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 CALIFORNIA AVE
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89509-1450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-355-7722
-----------------------------------------------------
Fax | 775-355-7116
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1782
-----------------------------------------------------
City | SPARKS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89432-1782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-240-1796
-----------------------------------------------------
Fax | 775-355-7116
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | LC-I 00043
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MI0312
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------