Provider Demographics
NPI:1548812274
Name:WILSON, KRISTEN NICOLE (LCSW)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:NICOLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 SW 46TH CT APT 211
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34474-6264
Mailing Address - Country:US
Mailing Address - Phone:309-825-8704
Mailing Address - Fax:
Practice Address - Street 1:4900 SW 46TH CT APT 211
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-6264
Practice Address - Country:US
Practice Address - Phone:309-825-8704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL22889221041S0200X
IL149.0168901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool