Provider Demographics
NPI:1841373792
Name:WILSON, KEITH B (PHD, CRC, LPC, NCC)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:B
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD, CRC, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 BERWICK DR
Mailing Address - Street 2:
Mailing Address - City:BOALSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16827-1611
Mailing Address - Country:US
Mailing Address - Phone:814-466-7577
Mailing Address - Fax:
Practice Address - Street 1:119 S BURROWES ST
Practice Address - Street 2:SUITE 603
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-3863
Practice Address - Country:US
Practice Address - Phone:814-237-1233
Practice Address - Fax:814-238-1875
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC000512101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional