Provider Demographics
NPI:1154049385
Name:WILSON, KIMARA
Entity type:Individual
Prefix:
First Name:KIMARA
Middle Name:
Last Name:WILSON
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 1:3506 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BROWNWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76801-6204
Mailing Address - Country:US
Mailing Address - Phone:830-857-1553
Mailing Address - Fax:
Practice Address - Street 1:311 BLUFFVIEW DR
Practice Address - Street 2:
Practice Address - City:BROWNWOOD
Practice Address - State:TX
Practice Address - Zip Code:76801-1907
Practice Address - Country:US
Practice Address - Phone:325-646-0707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109333235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX109333OtherLICENSED SPEECH LANGUAGE PATHOLOGIST