Provider Demographics
NPI:1801819495
Name:WILSON, LARRY AL (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:AL
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2708 E TANAGER TRL
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77632-0750
Mailing Address - Country:US
Mailing Address - Phone:409-291-6066
Mailing Address - Fax:903-938-4749
Practice Address - Street 1:2708 E TANAGER TRL
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77632-0750
Practice Address - Country:US
Practice Address - Phone:409-291-6066
Practice Address - Fax:903-938-4749
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14885101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health