Provider Demographics
NPI:1609022219
Name:WILSON, KEITH RAYMOND (LMHC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:RAYMOND
Last Name:WILSON
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 DANFORTH CRESCENT
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618
Mailing Address - Country:US
Mailing Address - Phone:585-732-1970
Mailing Address - Fax:585-486-1960
Practice Address - Street 1:1596 MONROE AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-1415
Practice Address - Country:US
Practice Address - Phone:585-732-1970
Practice Address - Fax:585-486-1960
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-14
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002526101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health