Provider Demographics
NPI:1972136984
Name:WILSON, TAYLOR (LPC)
Entity type:Individual
Prefix:
First Name:TAYLOR
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 1:1035 W GLEN OAKS LN STE 110
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3392
Mailing Address - Country:US
Mailing Address - Phone:262-244-6178
Mailing Address - Fax:262-299-3040
Practice Address - Street 1:17100 W NORTH AVE STE 300
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4436
Practice Address - Country:US
Practice Address - Phone:262-244-6177
Practice Address - Fax:262-299-3040
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8641-225101YP2500X
WI4566-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional