Provider Demographics
NPI:1295203016
Name:WILSON, PRISCILLA J (LPCC)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:PRISCILLA
Other - Middle Name:J
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:303 21ST ST STE 232
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:MN
Mailing Address - Zip Code:55055-1182
Mailing Address - Country:US
Mailing Address - Phone:763-273-0671
Mailing Address - Fax:
Practice Address - Street 1:6268 BOONE AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55428-2729
Practice Address - Country:US
Practice Address - Phone:651-560-0050
Practice Address - Fax:651-925-0257
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01981101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional