Provider Demographics
NPI:1932604055
Name:WILSON, BRYCE HAMILTON (LPC)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:HAMILTON
Last Name:WILSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 FORTVIEW RD STE 112G
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-7658
Mailing Address - Country:US
Mailing Address - Phone:512-630-0821
Mailing Address - Fax:
Practice Address - Street 1:1825 FORTVIEW RD STE 112G
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7658
Practice Address - Country:US
Practice Address - Phone:512-630-0821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69705101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional