Provider Demographics
NPI:1710951421
Name:WILSON, CINDY SUE (LPC)
Entity Type:Individual
Prefix:MS
First Name:CINDY
Middle Name:SUE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 E GROVERS AVE UNIT 63
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-1923
Mailing Address - Country:US
Mailing Address - Phone:480-234-3402
Mailing Address - Fax:480-922-5445
Practice Address - Street 1:11811 N TATUM BLVD STE 3031
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-1621
Practice Address - Country:US
Practice Address - Phone:480-234-3402
Practice Address - Fax:480-781-4522
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
AZLPC0534103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional