Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | LCP 086 (BSRB) | KS |
Y | 103T00000X | Psychologist | LCP 086 (BSRB) | KS |
N | 103TS0200X | School Psychologist | 1572833211 (KSDE) | KS |
NPI | 1083956924 |
---|---|
Provider Name | Patricia Diane Wilson |
First Address | Newton, KS 67114-5010 |
Second Address | Newton, KS 67114-5010 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/03/2013 |
Last Update Date | 18/03/2013 |