Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 1119 | CO |
Y | 103T00000X | Psychologist | 1119 | CO |
NPI | 1003167743 |
---|---|
Provider Name | Kent A Wilson |
First Address | Denver, CO 80211-5308 |
Second Address | Denver, CO 80211-5308 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2012 |
Last Update Date | 20/09/2012 |