Provider Demographics
NPI:1043604671
Name:WILSON, STEPHANIE ROSELIND (LPC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ROSELIND
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4735
Mailing Address - Country:US
Mailing Address - Phone:912-464-0830
Mailing Address - Fax:
Practice Address - Street 1:3110 PARKWOOD DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4735
Practice Address - Country:US
Practice Address - Phone:912-464-0830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-20
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008365101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional