Provider Demographics
NPI:1316196058
Name:WILSON, SALLY W (LMFT,CAC)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:W
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMFT,CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19382-3386
Mailing Address - Country:US
Mailing Address - Phone:610-436-0125
Mailing Address - Fax:
Practice Address - Street 1:225 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19382-3386
Practice Address - Country:US
Practice Address - Phone:610-436-0125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMF 000040106H00000X
PA2828101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)