Provider Demographics
NPI:1902118409
Name:WILSON, RICHARD (LPCC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 LUISA ST STE C
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4073
Mailing Address - Country:US
Mailing Address - Phone:505-231-4804
Mailing Address - Fax:
Practice Address - Street 1:1421 LUISA ST STE C
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4073
Practice Address - Country:US
Practice Address - Phone:505-231-4804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-13
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0132231101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health