Provider Demographics
NPI:1376604108
Name:WILSON, ALBERT GRAHAM IV (LPC)
Entity Type:Individual
Prefix:MR
First Name:ALBERT
Middle Name:GRAHAM
Last Name:WILSON
Suffix:IV
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 SELBY AVE
Mailing Address - Street 2:#316 UNION THERAPY
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-1852
Mailing Address - Country:US
Mailing Address - Phone:612-305-8081
Mailing Address - Fax:
Practice Address - Street 1:370 SELBY AVE
Practice Address - Street 2:#316 UNION THERAPY
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1852
Practice Address - Country:US
Practice Address - Phone:612-305-8081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN01026101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional