Healthcare Provider Details

I. General information

NPI: 1285404210
Provider Name (Legal Business Name): MARY WILSON LMFTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY GOULD

II. Dates (important events)

Enumeration Date: 01/02/2024
Last Update Date: 11/07/2025
Certification Date: 11/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 CENTER ST
MANCHESTER CT
06040-3926
US

IV. Provider business mailing address

928 MATIANUCK AVE
WINDSOR CT
06095-3237
US

V. Phone/Fax

Practice location:
  • Phone: 860-731-5522
  • Fax: 860-731-5536
Mailing address:
  • Phone: 860-986-2553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3643
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: