Healthcare Provider Details

I. General information

NPI: 1710967161
Provider Name (Legal Business Name): LYN WILSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 04/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3148 S 1100 W
WEST VALLEY CITY UT
84119-3304
US

IV. Provider business mailing address

1020 S MAIN ST
SALT LAKE CITY UT
84101-3176
US

V. Phone/Fax

Practice location:
  • Phone: 801-974-7740
  • Fax: 801-974-7767
Mailing address:
  • Phone: 801-538-2057
  • Fax: 801-974-7767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1276466004
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6848
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: