Provider Demographics
NPI:1770643983
Name:WILSON, MARY JUDITH (LPCC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JUDITH
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3559 STRATHMOOR DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1519
Mailing Address - Country:US
Mailing Address - Phone:937-299-5418
Mailing Address - Fax:
Practice Address - Street 1:245 WEST ELMWOOD DR.
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459
Practice Address - Country:US
Practice Address - Phone:937-432-0766
Practice Address - Fax:937-432-0768
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE3422101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health