Provider Demographics
NPI:1003424078
Name:WILSON, MARQUITA LACHETTE (MED, CMHT, LPC)
Entity Type:Individual
Prefix:MS
First Name:MARQUITA
Middle Name:LACHETTE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MED, CMHT, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 RIVER RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:MS
Mailing Address - Zip Code:39350-1009
Mailing Address - Country:US
Mailing Address - Phone:601-663-7917
Mailing Address - Fax:601-663-7696
Practice Address - Street 1:125 RIVER RIDGE CIR
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:MS
Practice Address - Zip Code:39350-1009
Practice Address - Country:US
Practice Address - Phone:601-663-7917
Practice Address - Fax:601-663-7696
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MS324167101YS0200X
MS2729101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool