Provider Demographics
NPI:1508176835
Name:WILSON, MARY LUCINDA (LMHC, NCC, CCMHC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LUCINDA
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMHC, NCC, CCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1536 SUNRISE PLAZA DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34714-6204
Mailing Address - Country:US
Mailing Address - Phone:407-502-8011
Mailing Address - Fax:
Practice Address - Street 1:1536 SUNRISE PLAZA DR STE 100
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34714-6204
Practice Address - Country:US
Practice Address - Phone:407-502-8011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-20
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH14268101YM0800X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional