Provider Demographics
NPI:1679809164
Name:WILSON, ELIZABETH A (LMHC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 WASHINGTON ST STE 312
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3330
Mailing Address - Country:US
Mailing Address - Phone:315-755-2665
Mailing Address - Fax:315-755-2660
Practice Address - Street 1:120 WASHINGTON ST STE 312
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3330
Practice Address - Country:US
Practice Address - Phone:315-755-2665
Practice Address - Fax:315-755-2660
Is Sole Proprietor?:No
Enumeration Date:2009-10-19
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4198101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional