MEDICARE: KIMBERLY LACKEY WILSON RMHCI

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	IMH28150	FL

General Provider Information

NPI Number	:	1295600724
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY LACKEY WILSON RMHCI

Provider Business Mailing Address
First Line	:	701 S HOWARD AVE # 106-137
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33606-2473
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3502 HENDERSON BLVD STE 229
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-3999
Country	:	US
Telephone Number	:	813-603-6083
Fax Number	:

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

Provider Enumeration Date	:	10/06/2025
Last Update Date	:	10/06/2025

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