MEDICARE: MS. KIMBERLY WILSON LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MFT19855	CA

General Provider Information

NPI Number	:	1245457761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KIMBERLY WILSON LMFT

Provider Business Mailing Address
First Line	:	2827 SILVERCREST ST
Second Line	:
City	:	PLACERVILLE
State	:	CA
Zip	:	95667-3459
Country	:	US
Telephone Number	:	530-626-5919
Fax Number	:

Provider Business Practice Location Address
First Line	:	6692 MERCHANDISE WAY STE B
Second Line	:
City	:	DIAMOND SPRINGS
State	:	CA
Zip	:	95619-9453
Country	:	US
Telephone Number	:	530-626-2589
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	07/08/2007

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