Provider Demographics
NPI:1215094974
Name:WILSON, CHARLENE (LIMHP)
Entity type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LIMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N 31ST AVE STE 212
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-2915
Mailing Address - Country:US
Mailing Address - Phone:402-378-8508
Mailing Address - Fax:402-939-0676
Practice Address - Street 1:105 N 31ST AVE STE 212
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-2915
Practice Address - Country:US
Practice Address - Phone:402-378-8508
Practice Address - Fax:402-939-0676
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NE1921101YP2500X
NE3878101YP2500X
NE960101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1921OtherPROFESSIONAL COUNSELOR
NE960OtherLICENSE INDEPENDENT MENTAL HEALTH PRACTITIONER
NE3878OtherMENTAL HEALTH PRACTITIONER