Healthcare Provider Details

I. General information

NPI: 1518363621
Provider Name (Legal Business Name): GILLIAN LAUREN WILSON LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2014
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4625 E BAY DR STE 103
CLEARWATER FL
33764-6866
US

IV. Provider business mailing address

119 MANDOLIN DR
WINTER HAVEN FL
33884-3581
US

V. Phone/Fax

Practice location:
  • Phone: 888-214-2144
  • Fax: 866-693-2298
Mailing address:
  • Phone: 888-214-2144
  • Fax: 866-693-2298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number12664
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12664
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12664
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberTPMC3042
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: