Provider Demographics
NPI:1548883390
Name:WILSON, KRISTA (LCPC)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 CUSTER AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-2273
Mailing Address - Country:US
Mailing Address - Phone:847-425-1500
Mailing Address - Fax:847-972-6277
Practice Address - Street 1:800 CUSTER AVE STE 5
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-2273
Practice Address - Country:US
Practice Address - Phone:847-425-1500
Practice Address - Fax:847-972-6277
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0017610101YM0800X
IL180.016352101YP2500X
IL178.016784101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180.016352OtherILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION - LCPC
IL178.016784OtherILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION - LPC
COLPCC.0017610OtherDEPARTMENT OF REGULATORY AGENCIES