Provider Demographics
NPI:1609975705
Name:WILSON, MARY J (MS LCPC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS LCPC
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 S 10TH
Mailing Address - Street 2:SUITE 510
Mailing Address - City:MT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864
Mailing Address - Country:US
Mailing Address - Phone:618-242-8139
Mailing Address - Fax:618-242-8141
Practice Address - Street 1:123 S 10TH
Practice Address - Street 2:SUITE 510
Practice Address - City:MT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864
Practice Address - Country:US
Practice Address - Phone:618-242-8139
Practice Address - Fax:618-242-8141
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180002360101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180002360OtherSTATE LICENSE NUMBER