Provider Demographics
NPI:1114348729
Name:WILSON, DEREK JAMES (LPC)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:JAMES
Last Name:WILSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 CARRIAGE CROSSING LN
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-5864
Mailing Address - Country:US
Mailing Address - Phone:860-471-3819
Mailing Address - Fax:
Practice Address - Street 1:360 BLOOMFIELD AVE STE 301
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-2700
Practice Address - Country:US
Practice Address - Phone:860-471-3819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-27
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
CT003206101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional