Provider Demographics
NPI:1114572146
Name:WILSON, WHITNEY (LPC)
Entity type:Individual
Prefix:
First Name:WHITNEY
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6457 GREENE ST FL 4
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-3265
Mailing Address - Country:US
Mailing Address - Phone:215-450-8391
Mailing Address - Fax:
Practice Address - Street 1:639 SWEDESFORD RD
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-1530
Practice Address - Country:US
Practice Address - Phone:610-616-5935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X
PAPC011393101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health