Provider Demographics
NPI:1528450673
Name:BYRNEWILSON, BRENDA (LCPC)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:BYRNEWILSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2616 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-5734
Mailing Address - Country:US
Mailing Address - Phone:815-501-1785
Mailing Address - Fax:
Practice Address - Street 1:2616 19TH AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-5734
Practice Address - Country:US
Practice Address - Phone:815-501-1785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007787101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional