Provider Demographics
NPI:1528861069
Name:WILSON, KEVIN (LAC)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 BRETONIAN DR
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-5763
Mailing Address - Country:US
Mailing Address - Phone:732-678-3505
Mailing Address - Fax:
Practice Address - Street 1:1350 CAMPUS PKWY STE 101
Practice Address - Street 2:
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07753-6841
Practice Address - Country:US
Practice Address - Phone:732-924-5589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00772000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health