Provider Demographics
NPI:1144326265
Name:WILSON PSYCHOLOGICAL ASSOCIATES PLLC
Entity type:Organization
Organization Name:WILSON PSYCHOLOGICAL ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:SPENCER
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:918-337-6050
Mailing Address - Street 1:501 S JOHNSTONE AVE
Mailing Address - Street 2:SUITE 503
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74003-6622
Mailing Address - Country:US
Mailing Address - Phone:918-337-6050
Mailing Address - Fax:918-337-6061
Practice Address - Street 1:501 S JOHNSTONE AVE
Practice Address - Street 2:SUITE 503
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74003-6622
Practice Address - Country:US
Practice Address - Phone:918-337-6050
Practice Address - Fax:918-337-6061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2023-09-21
Deactivation Date:2023-09-06
Deactivation Code:
Reactivation Date:2023-09-21
Provider Licenses
StateLicense IDTaxonomies
OK966103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200522095OtherMEDICARE NUMBER
OK200029610AMedicaid