MEDICARE: DR. LARRY AL WILSON PH.D.

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	14885	TX

General Provider Information

NPI Number	:	1801819495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY AL WILSON PH.D.

Provider Business Mailing Address
First Line	:	2708 E TANAGER TRL
Second Line	:
City	:	ORANGE
State	:	TX
Zip	:	77632-0750
Country	:	US
Telephone Number	:	409-291-6066
Fax Number	:	903-938-4749

Provider Business Practice Location Address
First Line	:	2708 E TANAGER TRL
Second Line	:
City	:	ORANGE
State	:	TX
Zip	:	77632-0750
Country	:	US
Telephone Number	:	409-291-6066
Fax Number	:	903-938-4749

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

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	07/08/2007

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