Provider Demographics
NPI:1225584188
Name:WILSON, DOMINIQUE M (LCPC)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1616 W MAIN ST STE 503
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1146
Mailing Address - Country:US
Mailing Address - Phone:618-703-3038
Mailing Address - Fax:
Practice Address - Street 1:1616 W MAIN ST STE 503
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1146
Practice Address - Country:US
Practice Address - Phone:618-703-3038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.011802101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health