MEDICARE: MS. KIMBERLY WILSON LPC

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	101YP2500X	Professional Counselor	LPC014060	GA
2	101YM0800X	Mental Health Counselor	LPC014060	GA

General Provider Information

NPI Number	:	1720861867
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KIMBERLY WILSON LPC

Provider Business Mailing Address
First Line	:	3238 LONG IRON PL
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30044-2513
Country	:	US
Telephone Number	:	678-653-3324
Fax Number	:

Provider Business Practice Location Address
First Line	:	3238 LONG IRON PL
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30044-2513
Country	:	US
Telephone Number	:	678-653-3324
Fax Number	:

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

Provider Enumeration Date	:	08/14/2023
Last Update Date	:	06/05/2025

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