Provider Demographics
NPI:1295074110
Name:WILSON, ANTOINETTE L (LPC)
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:ANTOINETTE
Other - Middle Name:
Other - Last Name:CANTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 66308
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11000 SCOTT ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77047-1500
Practice Address - Country:US
Practice Address - Phone:713-351-7360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-13
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64774101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080462703Medicaid