Provider Demographics
NPI:1326255282
Name:WILSON, KATHERINE J (LCPC)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ROUTE 1
Mailing Address - Street 2:BOX 86
Mailing Address - City:TIMEWELL
Mailing Address - State:IL
Mailing Address - Zip Code:62375
Mailing Address - Country:US
Mailing Address - Phone:217-617-2039
Mailing Address - Fax:217-773-2425
Practice Address - Street 1:700 SE CROSS ST
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:IL
Practice Address - Zip Code:62353-1561
Practice Address - Country:US
Practice Address - Phone:217-773-3325
Practice Address - Fax:217-773-2425
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional