Provider Demographics
NPI:1972072973
Name:WILSON, KIMBERLY-ANN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY-ANN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10910 CLARKSVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-6106
Mailing Address - Country:US
Mailing Address - Phone:410-313-6600
Mailing Address - Fax:
Practice Address - Street 1:9440 OLD FREDERICK RD
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-1799
Practice Address - Country:US
Practice Address - Phone:410-313-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05107235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist