Provider Demographics
NPI:1447745716
Name:WILSON, LATISHA DENISE (LPC, LMFT-A, LCDC-I)
Entity type:Individual
Prefix:
First Name:LATISHA
Middle Name:DENISE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC, LMFT-A, LCDC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2904 E STAN SCHLUETER LOOP # 68
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-4813
Mailing Address - Country:US
Mailing Address - Phone:254-523-6710
Mailing Address - Fax:
Practice Address - Street 1:507 N 8TH ST
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76541-4867
Practice Address - Country:US
Practice Address - Phone:254-523-6710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-28
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33788101YA0400X
TX79124101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX403747501Medicaid