MEDICARE: PRISCILLA J WILSON LPCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	CC01981	MN

General Provider Information

NPI Number	:	1295203016
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRISCILLA J WILSON LPCC

Provider Business Mailing Address
First Line	:	303 21ST ST STE 232
Second Line	:
City	:	NEWPORT
State	:	MN
Zip	:	55055-1182
Country	:	US
Telephone Number	:	763-273-0671
Fax Number	:

Provider Business Practice Location Address
First Line	:	6268 BOONE AVE N
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55428-2729
Country	:	US
Telephone Number	:	651-560-0050
Fax Number	:	651-925-0257

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2018
Last Update Date	:	03/27/2019

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