Provider Demographics
NPI:1407345192
Name:WILSON, DOMINIQUE MARIE (MA, LCPC, CRC)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, LCPC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 HIGH VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-6846
Mailing Address - Country:US
Mailing Address - Phone:317-900-6556
Mailing Address - Fax:
Practice Address - Street 1:785 WALL ST # 200
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1959
Practice Address - Country:US
Practice Address - Phone:618-367-2194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-08
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCI0365101Y00000X, 101YM0800X
IL180.012945101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health