Healthcare Provider Details

I. General information

NPI: 1053106633
Provider Name (Legal Business Name): DWILSON COUNSELING, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 04/14/2025
Certification Date: 04/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 PIERCE BLVD STE 200
O FALLON IL
62269-2584
US

IV. Provider business mailing address

2126 VILLAGE PKWY
SAN ANTONIO TX
78251-2611
US

V. Phone/Fax

Practice location:
  • Phone: 618-406-2490
  • Fax:
Mailing address:
  • Phone: 317-900-6556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DOMINIQUE WILSON
Title or Position: OWNER
Credential:
Phone: 618-406-2490