Provider Demographics
NPI:1720280555
Name:WILSON, KIMILEE YVONNE (PSYD)
Entity type:Individual
Prefix:DR
First Name:KIMILEE
Middle Name:YVONNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12865 STATE ROUTE 775
Mailing Address - Street 2:
Mailing Address - City:WILLOW WOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45696-9065
Mailing Address - Country:US
Mailing Address - Phone:740-643-2284
Mailing Address - Fax:
Practice Address - Street 1:1301 HAL GREER BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3803
Practice Address - Country:US
Practice Address - Phone:304-525-3334
Practice Address - Fax:304-525-3338
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1542103T00000X
WV1046103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810014579Medicaid
WVQ48079AMedicare PIN
KY7100091060Medicare PIN
OH2930350Medicare PIN