Provider Demographics
NPI:1912692104
Name:WILSON, SAMANTHA (LPA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3009 S COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-1309
Mailing Address - Country:US
Mailing Address - Phone:469-560-8696
Mailing Address - Fax:
Practice Address - Street 1:127 FAIRMEADE DR
Practice Address - Street 2:
Practice Address - City:TERRELL
Practice Address - State:TX
Practice Address - Zip Code:75160-4513
Practice Address - Country:US
Practice Address - Phone:469-560-8696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-05
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38683103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical