Provider Demographics
NPI:1922179118
Name:WILSON, CARRIE L (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 NIKKI VIEW DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4879
Mailing Address - Country:US
Mailing Address - Phone:813-685-9916
Mailing Address - Fax:813-657-1049
Practice Address - Street 1:1121 NIKKI VIEW DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4879
Practice Address - Country:US
Practice Address - Phone:813-685-9916
Practice Address - Fax:813-657-1049
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-11
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH4662101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health