Healthcare Provider Details

I. General information

NPI: 1316196058
Provider Name (Legal Business Name): SALLY W WILSON LMFT,CAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2008
Last Update Date: 09/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 S CHURCH ST
WEST CHESTER PA
19382-3386
US

IV. Provider business mailing address

225 S CHURCH ST
WEST CHESTER PA
19382-3386
US

V. Phone/Fax

Practice location:
  • Phone: 610-436-0125
  • Fax:
Mailing address:
  • Phone: 610-436-0125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2828
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMF 000040
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: