Healthcare Provider Details

I. General information

NPI: 1902118409
Provider Name (Legal Business Name): RICHARD WILSON LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2010
Last Update Date: 07/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 LUISA ST STE C
SANTA FE NM
87505-4073
US

IV. Provider business mailing address

1421 LUISA ST STE C
SANTA FE NM
87505-4073
US

V. Phone/Fax

Practice location:
  • Phone: 505-231-4804
  • Fax:
Mailing address:
  • Phone: 505-231-4804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0132231
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: