Provider Demographics
NPI:1316091119
Name:WILSON, KIMBERLY SHANNON (PHD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SHANNON
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 S NORTHSHORE DR
Mailing Address - Street 2:STE 105
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-7594
Mailing Address - Country:US
Mailing Address - Phone:865-584-4005
Mailing Address - Fax:865-584-5551
Practice Address - Street 1:5401 KINGSTON PIKE
Practice Address - Street 2:STE 170
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-5022
Practice Address - Country:US
Practice Address - Phone:865-584-4005
Practice Address - Fax:865-584-5551
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000002498103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3983201Medicaid
TN3983201Medicaid