Provider Demographics
NPI:1366400707
Name:WILSON, KENNETH SPENCER (PHD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:SPENCER
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:MS
Other - First Name:KRISTIN
Other - Middle Name:LEEAN
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:501 S JOHNSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74003-6638
Mailing Address - Country:US
Mailing Address - Phone:918-337-6050
Mailing Address - Fax:918-336-6061
Practice Address - Street 1:501 S JOHNSTONE AVE
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74003-6609
Practice Address - Country:US
Practice Address - Phone:918-337-6050
Practice Address - Fax:918-336-6061
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK966103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKQ18505Medicare UPIN