| Doctor Name: | DR. KIMBERLY RENEE WILSON |
| NPI Number: | 1770976144 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | PHD/CCC-SLP |
| License Number: | SLP006884 |
| Business Practice Address: | 572 Preserve Park Dr Loganville, GA - 300525872 |
| Business Phone Number: | 6786674650 |
| Business Fax Number: | |
| Mailing Address: | 572 Preserve Park Dr, LOGANVILLE |
| State: | GA |
| Postal Code: | 300525872 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 03/10/2015 |
| NPI Last Update Date: | 03/10/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 235Z00000X |
| License Number: | SLP006884 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | GA |
| Taxonomy Type: | Speech, Language and Hearing Service Providers |
| Taxonomy Classification: | Speech-Language Pathologist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A speech pathologist is a person qualified by a master |