Provider Demographics
NPI:1124835509
Name:WILSON, WESLEY MARK (LPC-IT)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:MARK
Last Name:WILSON
Suffix:
Gender:
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1062
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-1062
Mailing Address - Country:US
Mailing Address - Phone:715-634-0222
Mailing Address - Fax:
Practice Address - Street 1:10752 BEAL AVE
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-6435
Practice Address - Country:US
Practice Address - Phone:715-533-0736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-18
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8187-226101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100305836Medicaid