Provider Demographics
NPI:1003797507
Name:WILSON, TY SHAWN
Entity type:Individual
Prefix:MR
First Name:TY
Middle Name:SHAWN
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 COTTONWOOD CREEK TRL STE 300
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-2688
Mailing Address - Country:US
Mailing Address - Phone:833-966-2730
Mailing Address - Fax:
Practice Address - Street 1:1210 COTTONWOOD CREEK TRL STE 300
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-2688
Practice Address - Country:US
Practice Address - Phone:833-966-2730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-10
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health