Provider Demographics
NPI:1386133148
Name:WILSON, KIMBERLY (MFTT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MFTT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5432 COVE AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-6311
Mailing Address - Country:US
Mailing Address - Phone:614-370-2348
Mailing Address - Fax:
Practice Address - Street 1:5432 COVE AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-6311
Practice Address - Country:US
Practice Address - Phone:161-437-0234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-08
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 251S00000X
OHM1900148TRNE106H00000X
OH167556101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No251S00000XAgenciesCommunity/Behavioral Health