Provider Demographics
NPI:1992087589
Name:WILSON, WOODROW III (LPC)
Entity type:Individual
Prefix:MR
First Name:WOODROW
Middle Name:
Last Name:WILSON
Suffix:III
Gender:M
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:PO BOX 11064
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-1001
Mailing Address - Country:US
Mailing Address - Phone:870-520-5014
Mailing Address - Fax:
Practice Address - Street 1:3305 E HIGHLAND DR STE B
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6491
Practice Address - Country:US
Practice Address - Phone:870-520-5014
Practice Address - Fax:870-520-5015
Is Sole Proprietor?:No
Enumeration Date:2011-09-09
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1012081101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR228145719Medicaid