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General NPI Number Information
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NPI Number | 1366831349
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Entity Type | Organization
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Legal Business Name | REVLON WILSON
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Dates
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Enumeration Date | 01/14/2015
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Last Update Date | 01/14/2015
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Provider Practice Location Address
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Address Line | 13021 LEGENDARY DR APT 1334
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City | AUSTIN
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State | TX
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Zip | 78727-3934
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Country | US
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Telephone | 773-203-2329
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Fax |
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Provider Business Mailing Address
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Address Line | 13021 LEGENDARY DR APT 1334
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City | AUSTIN
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State | TX
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Zip | 78727-3934
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | LICENSED PROFESSIONAL COUNSELOR
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Name | REVLON DIONE WILSON
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Credential | M.A LPC
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Telephone | 773-203-2329
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | 72882
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 72882
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License Number State | TX
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