Provider Demographics
NPI:1700183837
Name:WILSON, MISTIE RAYLENE (MS, LPC)
Entity Type:Individual
Prefix:MS
First Name:MISTIE
Middle Name:RAYLENE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 N CALDWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:KS
Mailing Address - Zip Code:67022-8624
Mailing Address - Country:US
Mailing Address - Phone:806-223-9658
Mailing Address - Fax:806-553-4021
Practice Address - Street 1:223 N CALDWELL BLVD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:KS
Practice Address - Zip Code:67022-8624
Practice Address - Country:US
Practice Address - Phone:806-223-9658
Practice Address - Fax:806-553-4021
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-25
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS03253101YM0800X
OK10551101YM0800X
TX65776101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health