Provider Demographics
NPI:1386380889
Name:WILSON, TIARA (LPC)
Entity type:Individual
Prefix:
First Name:TIARA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 CANTERBURY DR
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:PA
Mailing Address - Zip Code:15126-9191
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 PARK PLACE DR STE 110
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-2063
Practice Address - Country:US
Practice Address - Phone:304-460-5123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-07
Last Update Date:2022-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC014137101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional