Provider Demographics
NPI:1043895931
Name:WILSON, BROOKE C (LPC)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:C
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 SUNDANCE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-6580
Mailing Address - Country:US
Mailing Address - Phone:937-367-9242
Mailing Address - Fax:
Practice Address - Street 1:427 SUNDANCE WAY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-6580
Practice Address - Country:US
Practice Address - Phone:937-367-9242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-12
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1800875101YP2500X
TX79942101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional