Provider Demographics
NPI:1073025938
Name:WILSON, TERESA LYNN (MSSA, LICDC, LSW)
Entity type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSSA, LICDC, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8120 GARNET DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45458-2141
Mailing Address - Country:US
Mailing Address - Phone:937-522-0960
Mailing Address - Fax:
Practice Address - Street 1:3008 SUDBURY DR
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45420-1129
Practice Address - Country:US
Practice Address - Phone:937-310-1269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-01
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1802256101YM0800X
OH161506101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health