Provider Demographics
NPI:1679997555
Name:WILSON, KENNETH G (PHD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:G
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7251 E 49TH AVE
Mailing Address - Street 2:
Mailing Address - City:COMMERCE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:80022-4714
Mailing Address - Country:US
Mailing Address - Phone:303-321-2533
Mailing Address - Fax:303-468-6199
Practice Address - Street 1:7251 E 49TH AVE
Practice Address - Street 2:
Practice Address - City:COMMERCE CITY
Practice Address - State:CO
Practice Address - Zip Code:80022-4714
Practice Address - Country:US
Practice Address - Phone:303-321-2533
Practice Address - Fax:303-468-6199
Is Sole Proprietor?:No
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL692103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical