Provider Demographics
NPI:1699555912
Name:WILSON, ANDREA LYN (LMHC)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16703 EARLY RISER AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-0192
Mailing Address - Country:US
Mailing Address - Phone:813-679-9860
Mailing Address - Fax:
Practice Address - Street 1:16703 EARLY RISER AVE STE 108
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34638-0192
Practice Address - Country:US
Practice Address - Phone:813-679-9860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH21772101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health