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General NPI Number Information
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NPI Number | 1407345192
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Entity Type | Individual
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Provider Name | DOMINIQUE MARIE WILSON MA, LCPC, CRC
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Gender | Female
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Dates
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Enumeration Date | 05/08/2018
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Last Update Date | 08/11/2020
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Provider Practice Location Address
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Address Line | 785 WALL ST # 200
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City | O FALLON
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State | IL
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Zip | 62269-1959
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Country | US
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Telephone | 618-367-2194
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Fax |
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Provider Business Mailing Address
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Address Line | 1109 HIGH VALLEY LN
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City | BELLEVILLE
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State | IL
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Zip | 62221-6846
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Country | US
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Telephone | 317-900-6556
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | CI0365
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License Number State | NV
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | CI0365
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License Number State | NV
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180.012945
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License Number State | IL
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