Provider Demographics
NPI:1386410629
Name:WILSON, JUSTIN MARK (MS, LPC)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:MARK
Last Name:WILSON
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 OXFORD ST
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-4926
Mailing Address - Country:US
Mailing Address - Phone:732-877-4678
Mailing Address - Fax:
Practice Address - Street 1:1165 OXFORD ST
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-4926
Practice Address - Country:US
Practice Address - Phone:732-877-4678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00790400101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health