Provider Demographics
NPI:1598188286
Name:WILSON, DWYLA (LPC-S, NCC)
Entity Type:Individual
Prefix:
First Name:DWYLA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC-S, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5842 MOHAWK RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-1367
Mailing Address - Country:US
Mailing Address - Phone:601-693-1234
Mailing Address - Fax:601-693-1312
Practice Address - Street 1:5842 MOHAWK RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-1367
Practice Address - Country:US
Practice Address - Phone:601-693-1234
Practice Address - Fax:601-693-1312
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-30
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS246433101Y00000X
MS120101YM0800X
MS1578101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor