Provider Demographics
NPI:1942411095
Name:WILSON, DARRELL A (LPC, CRC)
Entity Type:Individual
Prefix:MR
First Name:DARRELL
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:LPC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 S FLORIDA CT
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-2900
Mailing Address - Country:US
Mailing Address - Phone:417-781-8554
Mailing Address - Fax:
Practice Address - Street 1:2520 S FLORIDA CT
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-2900
Practice Address - Country:US
Practice Address - Phone:417-781-8554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001025510101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional