Provider Demographics
NPI:1972158111
Name:WILSON, MALINDA GAYLE (LPC)
Entity Type:Individual
Prefix:
First Name:MALINDA
Middle Name:GAYLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1665 CROSSHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75077-2422
Mailing Address - Country:US
Mailing Address - Phone:214-794-5111
Mailing Address - Fax:
Practice Address - Street 1:2016 JUSTIN RD STE 350
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75077-7180
Practice Address - Country:US
Practice Address - Phone:972-317-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX78815101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional