Provider Demographics
NPI:1568773190
Name:WILSON, DIERDRE RYLENE (MA, LPCC)
Entity Type:Individual
Prefix:MRS
First Name:DIERDRE
Middle Name:RYLENE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 MONTGOMERY BLVD NE STE B203
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1202
Mailing Address - Country:US
Mailing Address - Phone:505-421-0814
Mailing Address - Fax:
Practice Address - Street 1:4600 MONTGOMERY BLVD NE STE B203
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1202
Practice Address - Country:US
Practice Address - Phone:505-421-0814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0162741101YM0800X
NM0190311101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health