Provider Demographics
NPI:1154949626
Name:WILSON, RENEE (PH D, LPC-S)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:WILSON
Suffix:
Gender:
Credentials:PH D, LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12742 E 22ND ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74129-6004
Mailing Address - Country:US
Mailing Address - Phone:951-892-9349
Mailing Address - Fax:
Practice Address - Street 1:12742 E 22ND ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-6004
Practice Address - Country:US
Practice Address - Phone:951-892-9349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7082101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty