Provider Demographics
NPI:1972853380
Name:WILSON, DARLENE LYNN (LPC)
Entity Type:Individual
Prefix:
First Name:DARLENE
Middle Name:LYNN
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 1:1597 NORTH HIGHWAY 63
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MO
Mailing Address - Zip Code:65483
Mailing Address - Country:US
Mailing Address - Phone:417-967-2887
Mailing Address - Fax:417-967-2201
Practice Address - Street 1:1597 N. HIGHWAY 63
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MO
Practice Address - Zip Code:46548
Practice Address - Country:US
Practice Address - Phone:417-967-2887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011024575101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1972853380Medicaid