Provider Demographics
NPI:1023536463
Name:WILSON, EBONY N (LPC, LADC)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:N
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 HIGHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-5826
Mailing Address - Country:US
Mailing Address - Phone:860-626-5002
Mailing Address - Fax:
Practice Address - Street 1:65 HIGHFIELD DR
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-5826
Practice Address - Country:US
Practice Address - Phone:860-626-5002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-06
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1267101YA0400X
101YM0800X
CT4405101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health