Provider Demographics
NPI:1780232231
Name:WILKERSON, MARK ANDREW (LPC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANDREW
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N2280 GLEN ROSE LN
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54942-9794
Mailing Address - Country:US
Mailing Address - Phone:816-210-2068
Mailing Address - Fax:
Practice Address - Street 1:1835 E EDGEWOOD DR STE 575
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-9407
Practice Address - Country:US
Practice Address - Phone:920-944-9407
Practice Address - Fax:920-944-9413
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7565101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty