Provider Demographics
NPI:1992019582
Name:WILSON, RYAN JOHN (LPC CANDIDATE)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:JOHN
Last Name:WILSON
Suffix:
Gender:M
Credentials:LPC CANDIDATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1629 S. 108TH E. PL.
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74128
Mailing Address - Country:US
Mailing Address - Phone:918-895-4018
Mailing Address - Fax:
Practice Address - Street 1:2725 E. SKELLY DR.
Practice Address - Street 2:SUITE 202
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74128
Practice Address - Country:US
Practice Address - Phone:918-382-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health