Healthcare Provider Details

I. General information

NPI: 1073025938
Provider Name (Legal Business Name): TERESA LYNN WILSON MSSA, LICDC, LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2017
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3008 SUDBURY DR
KETTERING OH
45420-1129
US

IV. Provider business mailing address

8120 GARNET DR
DAYTON OH
45458-2141
US

V. Phone/Fax

Practice location:
  • Phone: 937-310-1269
  • Fax:
Mailing address:
  • Phone: 937-522-0960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1802256
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number161506
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: