Provider Demographics
NPI:1770894073
Name:WILSON, MARIE ELIZABETH (LPCC)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:ELIZABETH
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:E
Other - Last Name:WESSELMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPCC
Mailing Address - Street 1:4339 WINSTON AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41015-1739
Mailing Address - Country:US
Mailing Address - Phone:859-835-2573
Mailing Address - Fax:859-727-6327
Practice Address - Street 1:4339 WINSTON AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41015-1739
Practice Address - Country:US
Practice Address - Phone:859-835-2573
Practice Address - Fax:859-727-6327
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY103365101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100291250Medicaid