Provider Demographics
NPI:1538344908
Name:WILSON, LARRY DWIGHT JR (LMHP, LADC, CPC)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:DWIGHT
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:LMHP, LADC, CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 N 60TH ST
Mailing Address - Street 2:CATHOLIC CHARITIES
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-3402
Mailing Address - Country:US
Mailing Address - Phone:402-554-0520
Mailing Address - Fax:402-551-8797
Practice Address - Street 1:3020 18TH ST SUITE 17
Practice Address - Street 2:CATHOLIC CHARITIES
Practice Address - City:COLUMBUS
Practice Address - State:NE
Practice Address - Zip Code:68601-4254
Practice Address - Country:US
Practice Address - Phone:402-563-3833
Practice Address - Fax:402-562-8714
Is Sole Proprietor?:No
Enumeration Date:2008-01-04
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE819101YA0400X
NE1770101YP2500X
NE3523101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health