Provider Demographics
NPI:1710967161
Name:WILSON, LYN (LPC)
Entity Type:Individual
Prefix:MS
First Name:LYN
Middle Name:
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 1:1020 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-3176
Mailing Address - Country:US
Mailing Address - Phone:801-538-2057
Mailing Address - Fax:801-974-7767
Practice Address - Street 1:3148 S 1100 W
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-3304
Practice Address - Country:US
Practice Address - Phone:801-974-7740
Practice Address - Fax:801-974-7767
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1276466004101YM0800X
NC6848101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional