Provider Demographics
NPI:1437757077
Name:WILSON, DAWN MARCELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:MARCELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1238
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75710-1238
Mailing Address - Country:US
Mailing Address - Phone:903-595-5525
Mailing Address - Fax:903-531-9328
Practice Address - Street 1:1358 E RICHARDS ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-6153
Practice Address - Country:US
Practice Address - Phone:903-595-5525
Practice Address - Fax:903-531-9328
Is Sole Proprietor?:No
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX690321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical