Healthcare Provider Details

I. General information

NPI: 1386696623
Provider Name (Legal Business Name): J PATRICK WILSON MA LMFT LPC-S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 01/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 HEYMANN BLVD BLDG. B, STE. 4
LAFAYETTE LA
70503-2465
US

IV. Provider business mailing address

PO BOX 53527
LAFAYETTE LA
70505-3527
US

V. Phone/Fax

Practice location:
  • Phone: 337-233-1775
  • Fax: 337-233-1775
Mailing address:
  • Phone: 337-233-1775
  • Fax: 337-233-1775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number8
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2653
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: