Provider Demographics
NPI:1083499255
Name:AUDREY WILSON, LCPC
Entity Type:Organization
Organization Name:AUDREY WILSON, LCPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, CADC, CTP
Authorized Official - Phone:630-740-8922
Mailing Address - Street 1:1 MERCHANTS PLZ STE 206
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-9453
Mailing Address - Country:US
Mailing Address - Phone:630-740-8922
Mailing Address - Fax:
Practice Address - Street 1:1 MERCHANTS PLZ STE 206
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-9453
Practice Address - Country:US
Practice Address - Phone:630-740-8922
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty