Provider Demographics
NPI:1922230663
Name:WILSON, HEIDI L (LPC)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:L
Other - Last Name:KUBERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS LPC
Mailing Address - Street 1:715 STATE ROAD 79
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOYCEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54725-7535
Mailing Address - Country:US
Mailing Address - Phone:715-643-2445
Mailing Address - Fax:
Practice Address - Street 1:715 STATE ROAD 79
Practice Address - Street 2:SUITE B
Practice Address - City:BOYCEVILLE
Practice Address - State:WI
Practice Address - Zip Code:54725-7535
Practice Address - Country:US
Practice Address - Phone:715-643-2445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4296-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional