Provider Demographics
NPI:1871066787
Name:WILSON, ANTONIO M (LPC-ASSOCIATE)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:M
Last Name:WILSON
Suffix:
Gender:M
Credentials:LPC-ASSOCIATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 MAIN ST APT 707
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77002-7887
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3423 WUTHERING HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77045-4552
Practice Address - Country:US
Practice Address - Phone:318-676-9403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX93275101YM0800X, 101YM0800X
251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes251B00000XAgenciesCase Management