Provider Demographics
NPI:1255603635
Name:WILSON, TONY (MED,LPC)
Entity type:Individual
Prefix:MR
First Name:TONY
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:MED,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:LINDSAY
Mailing Address - State:OK
Mailing Address - Zip Code:73052-0306
Mailing Address - Country:US
Mailing Address - Phone:405-756-6082
Mailing Address - Fax:405-310-4052
Practice Address - Street 1:14844 E COUNTY ROAD 1520
Practice Address - Street 2:
Practice Address - City:LINDSAY
Practice Address - State:OK
Practice Address - Zip Code:73052-9299
Practice Address - Country:US
Practice Address - Phone:405-756-6082
Practice Address - Fax:405-310-4052
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-01
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK-4702101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health