Provider Demographics
NPI:1720198294
Name:WILSON, JOEL SHANE (MS, LPCC)
Entity Type:Individual
Prefix:MR
First Name:JOEL
Middle Name:SHANE
Last Name:WILSON
Suffix:
Gender:M
Credentials:MS, LPCC
Other - Prefix:
Other - First Name:J
Other - Middle Name:SHANE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, LPCC
Mailing Address - Street 1:10011 SEATONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-3541
Mailing Address - Country:US
Mailing Address - Phone:502-472-9833
Mailing Address - Fax:502-805-0600
Practice Address - Street 1:155 LEES VALLEY RD
Practice Address - Street 2:
Practice Address - City:SHEPHERDSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40165-6143
Practice Address - Country:US
Practice Address - Phone:502-472-9833
Practice Address - Fax:502-805-0600
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0550101YP2500X
TX18552101YP2500X
KY103656101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0550OtherLICENSE PROFESSIONAL CLINICAL COUNSELOR
11662641OtherCAQH PROVIDER ID
TX18552OtherLICENSE PROFESSIONAL COUNSELOR
KY7100267760Medicaid
TX162300103Medicaid
61254OtherNATIONAL CERTIFIED COUNSELOR
KY103656OtherUPDATED KY LICENSE PROFESSIONAL COUNSELOR NUMBER