MEDICARE: REVLON WILSON MA, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	72882	TX
2	101YP2500X	Professional Counselor	72882	TX

General Provider Information

NPI Number	:	1275922775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REVLON WILSON MA, LPC

Provider Business Mailing Address
First Line	:	PO BOX 2119
Second Line	:
City	:	HARKER HEIGHTS
State	:	TX
Zip	:	76548-0119
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1523 AZTEC TRCE APT A
Second Line	:
City	:	HARKER HEIGHTS
State	:	TX
Zip	:	76548-2987
Country	:	US
Telephone Number	:	773-203-2329
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/21/2015
Last Update Date	:	03/17/2018

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