Provider Demographics
NPI:1598340093
Name:WILSON, SUSAN (LCPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
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 1:1583 365N AVE
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:IL
Mailing Address - Zip Code:62378-2106
Mailing Address - Country:US
Mailing Address - Phone:217-242-6036
Mailing Address - Fax:
Practice Address - Street 1:127 S LIBERTY ST
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:IL
Practice Address - Zip Code:62681-1419
Practice Address - Country:US
Practice Address - Phone:217-322-4373
Practice Address - Fax:217-322-2138
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004241101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional