Provider Demographics
NPI:1467125419
Name:WILSON, ANGELA RENEE (LPC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:RENEE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-3526
Mailing Address - Country:US
Mailing Address - Phone:618-267-3968
Mailing Address - Fax:
Practice Address - Street 1:3 CUSUMANO PROFESSIONAL PLAZA DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6736
Practice Address - Country:US
Practice Address - Phone:618-267-3968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.016894101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional