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General NPI Number Information
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NPI Number | 1609022219
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Entity Type | Individual
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Provider Name | KEITH RAYMOND WILSON LMHC
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Gender | Male
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Dates
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Enumeration Date | 08/14/2008
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Last Update Date | 12/02/2013
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Provider Practice Location Address
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Address Line | 1596 MONROE AVE
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City | ROCHESTER
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State | NY
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Zip | 14618-1415
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Country | US
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Telephone | 585-732-1970
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Fax | 585-486-1960
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Provider Business Mailing Address
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Address Line | 46 DANFORTH CRESCENT
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City | ROCHESTER
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State | NY
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Zip | 14618
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Country | US
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Telephone | 585-732-1970
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Fax | 585-486-1960
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 002526
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License Number State | NY
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