MEDICARE: MR. ALBERT GRAHAM WILSON IV 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	101YP2500X	Professional Counselor	01026	MN

General Provider Information

NPI Number	:	1376604108
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALBERT GRAHAM WILSON IV LPC

Provider Business Mailing Address
First Line	:	370 SELBY AVE
Second Line	:	#316 UNION THERAPY
City	:	SAINT PAUL
State	:	MN
Zip	:	55102-1852
Country	:	US
Telephone Number	:	612-305-8081
Fax Number	:

Provider Business Practice Location Address
First Line	:	370 SELBY AVE
Second Line	:	#316 UNION THERAPY
City	:	SAINT PAUL
State	:	MN
Zip	:	55102-1852
Country	:	US
Telephone Number	:	612-305-8081
Fax Number	:

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

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	12/06/2012

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