Provider Demographics
NPI:1982949988
Name:WILSON, KEITH L III (MS, LPC)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:L
Last Name:WILSON
Suffix:III
Gender:M
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 1:1330 E CHERRY ST # 12
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-3429
Mailing Address - Country:US
Mailing Address - Phone:417-761-9598
Mailing Address - Fax:
Practice Address - Street 1:1330 E CHERRY ST # 12
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-3429
Practice Address - Country:US
Practice Address - Phone:417-761-9598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-01
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012037415101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1982949988Medicaid
MO1801285440Medicaid