Basic Information
| Provider Information | |||||||||
| NPI: | 1578738308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | KIMMEL | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1387 | ||||||||
| Address2: | |||||||||
| City: | HAYDEN LAKE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838351387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084150299 | ||||||||
| FaxNumber: | 2086252070 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 N IRONWOOD PL STE 100 | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087694222 | ||||||||
| FaxNumber: | 8448037399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2008 | ||||||||
| LastUpdateDate: | 07/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | LCPC-5367 | ID | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 5367 | ID | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | LCPC-5367 | ID | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | LCPC-5367 | ID | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.