Healthcare Provider Details

I. General information

NPI: 1063622439
Provider Name (Legal Business Name): PAUL THOMAS WILSON LMHC, LMFT, LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 11/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 SIMPSON ST
GREENCASTLE IN
46135-0066
US

IV. Provider business mailing address

PO BOX 792
GREENCASTLE IN
46135-0792
US

V. Phone/Fax

Practice location:
  • Phone: 765-658-6776
  • Fax:
Mailing address:
  • Phone: 765-658-6776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39000877A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number33002523A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35001054A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: