Provider Demographics
NPI:1194785287
Name:WILSON, KENNETH I (PSYD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:I
Last Name:WILSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 ALFRED ST STE 200
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-1915
Mailing Address - Country:US
Mailing Address - Phone:781-646-0500
Mailing Address - Fax:781-646-7130
Practice Address - Street 1:12 ALFRED ST STE 200
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1915
Practice Address - Country:US
Practice Address - Phone:781-646-0500
Practice Address - Fax:781-646-7130
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2020-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3882103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW03965Medicare ID - Type Unspecified