Provider Demographics
NPI:1114704343
Name:WILSON, SEAN AVERY (PLPC)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:AVERY
Last Name:WILSON
Suffix:
Gender:M
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 LYLE CURTIS CIR
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-2518
Mailing Address - Country:US
Mailing Address - Phone:573-855-5950
Mailing Address - Fax:
Practice Address - Street 1:413 ROUTE 66 W
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-2114
Practice Address - Country:US
Practice Address - Phone:573-774-4198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023035575101YP1600X, 101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health