Provider Demographics
NPI:1386397164
Name:WILSON, MYSHALA (LPC)
Entity type:Individual
Prefix:
First Name:MYSHALA
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 1:360 MAIN ST STE 2D
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3375
Mailing Address - Country:US
Mailing Address - Phone:203-449-6399
Mailing Address - Fax:
Practice Address - Street 1:360 MAIN ST STE 2D
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3375
Practice Address - Country:US
Practice Address - Phone:860-248-6046
Practice Address - Fax:844-264-0237
Is Sole Proprietor?:No
Enumeration Date:2022-02-01
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004997101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional