Provider Demographics
NPI:1790057453
Name:PRISCILLA WILSON, LMHP, NCC
Entity Type:Organization
Organization Name:PRISCILLA WILSON, LMHP, NCC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMHP, NCC
Authorized Official - Phone:402-720-5129
Mailing Address - Street 1:230 E 22ND ST STE 3
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-2661
Mailing Address - Country:US
Mailing Address - Phone:402-720-5129
Mailing Address - Fax:402-727-4839
Practice Address - Street 1:230 E 22ND ST STE 3
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-2661
Practice Address - Country:US
Practice Address - Phone:402-720-5129
Practice Address - Fax:402-727-4839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2417101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025233400Medicaid