Provider Demographics
NPI:1467675975
Name:WILSON, KORY DAVID (LPC-3463)
Entity Type:Individual
Prefix:MR
First Name:KORY
Middle Name:DAVID
Last Name:WILSON
Suffix:
Gender:M
Credentials:LPC-3463
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 PIONEER RD APT 8301
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-5285
Mailing Address - Country:US
Mailing Address - Phone:208-521-8173
Mailing Address - Fax:
Practice Address - Street 1:218 DIVIDEND DR STE 3
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-3510
Practice Address - Country:US
Practice Address - Phone:208-359-9683
Practice Address - Fax:208-359-9683
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-3463101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional