Healthcare Provider Details

I. General information

NPI: 1053206490
Provider Name (Legal Business Name): AUTUMN LYNNE WILSON MA, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2025
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1884 MAHOGANY ST
MORA MN
55051-7111
US

IV. Provider business mailing address

7145 375TH AVE NW
DALBO MN
55017-8403
US

V. Phone/Fax

Practice location:
  • Phone: 320-339-9963
  • Fax:
Mailing address:
  • Phone: 763-567-3875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5036
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: