Provider Demographics
NPI:1477184075
Name:WILBURN, MERCEDES (LPC)
Entity Type:Individual
Prefix:MS
First Name:MERCEDES
Middle Name:
Last Name:WILBURN
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 1:1225 BLUEGRASS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63137-1209
Mailing Address - Country:US
Mailing Address - Phone:314-783-7033
Mailing Address - Fax:
Practice Address - Street 1:3751 PENNRIDGE DR STE 119
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-1244
Practice Address - Country:US
Practice Address - Phone:636-336-6874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-01
Last Update Date:2020-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016045130101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional