Provider Demographics
NPI:1649404492
Name:WILSON, LEE (LCDC II)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:LCDC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4455 HORIZON HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-2258
Mailing Address - Country:US
Mailing Address - Phone:210-321-2700
Mailing Address - Fax:210-321-2720
Practice Address - Street 1:4455 HORIZON HILL BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-2258
Practice Address - Country:US
Practice Address - Phone:210-321-2700
Practice Address - Fax:210-321-2720
Is Sole Proprietor?:No
Enumeration Date:2009-05-08
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50261101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)