Provider Demographics
NPI:1225506264
Name:CHINHAMO-WILSON, ITAI (LPC CANDIDATE)
Entity Type:Individual
Prefix:MRS
First Name:ITAI
Middle Name:
Last Name:CHINHAMO-WILSON
Suffix:
Gender:F
Credentials:LPC CANDIDATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 NE ROGERS LN APT 1
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-1735
Mailing Address - Country:US
Mailing Address - Phone:803-807-8998
Mailing Address - Fax:
Practice Address - Street 1:1802 NW FERRIS AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-5625
Practice Address - Country:US
Practice Address - Phone:580-585-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health