Provider Demographics
NPI:1073001806
Name:WILSON, THERESA LEE (MA LPC)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:LEE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5508 28TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-3304
Mailing Address - Country:US
Mailing Address - Phone:806-401-1738
Mailing Address - Fax:
Practice Address - Street 1:3705 AVENUE A
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79404-2439
Practice Address - Country:US
Practice Address - Phone:806-401-1738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75787101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional