Provider Demographics
NPI:1316953524
Name:WILSON, KIMBERLY ANN (PHD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
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 1:61 AVENIDA DE ORINDA
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ORINDA
Mailing Address - State:CA
Mailing Address - Zip Code:94563-2327
Mailing Address - Country:US
Mailing Address - Phone:510-375-1682
Mailing Address - Fax:
Practice Address - Street 1:401 QUARRY RD
Practice Address - Street 2:PSYCHIATRY AND BEHAVIORAL SCIENCES
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1419
Practice Address - Country:US
Practice Address - Phone:650-723-6308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20184103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical