Provider Demographics
NPI:1538687702
Name:WILKERSON, KRISTIN DABBS
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:DABBS
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 HEALTHWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-4470
Mailing Address - Country:US
Mailing Address - Phone:410-334-6961
Mailing Address - Fax:410-334-6362
Practice Address - Street 1:29520 CANVASBACK DRIVE
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601
Practice Address - Country:US
Practice Address - Phone:410-822-5007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-07
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MD1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD609550002Medicaid