Provider Demographics
NPI:1578738308
Name:WILSON, KATIE (LCPC)
Entity Type:Individual
Prefix:MS
First Name:KATIE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1387
Mailing Address - Street 2:
Mailing Address - City:HAYDEN LAKE
Mailing Address - State:ID
Mailing Address - Zip Code:83835-1387
Mailing Address - Country:US
Mailing Address - Phone:208-415-0299
Mailing Address - Fax:208-625-2070
Practice Address - Street 1:2201 N IRONWOOD PL STE 100
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2670
Practice Address - Country:US
Practice Address - Phone:208-769-4222
Practice Address - Fax:844-803-7399
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-5367101Y00000X, 101YM0800X, 101YP2500X
ID5367101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty