Provider Demographics
NPI:1598916280
Name:WILSON FOWLER, MARY LESLIE (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LESLIE
Last Name:WILSON FOWLER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MARY LESLIE
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:403 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MS
Mailing Address - Zip Code:38967-1832
Mailing Address - Country:US
Mailing Address - Phone:662-582-3193
Mailing Address - Fax:
Practice Address - Street 1:1800 HILL DR STE E
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5071
Practice Address - Country:US
Practice Address - Phone:662-582-3193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1157101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional