Provider Demographics
NPI:1366831349
Name:REVLON WILSON
Entity Type:Organization
Organization Name:REVLON WILSON
Other - Org Name:NO OTHER WAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:REVLON
Authorized Official - Middle Name:DIONE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA LPC
Authorized Official - Phone:773-203-2329
Mailing Address - Street 1:13021 LEGENDARY DR
Mailing Address - Street 2:APT 1334
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78727-3934
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13021 LEGENDARY DR
Practice Address - Street 2:APT 1334
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78727-3934
Practice Address - Country:US
Practice Address - Phone:773-203-2329
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX72882251B00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management