Provider Demographics
NPI:1992132757
Name:WILSON, TERESA LOVE (LPCC)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:LOVE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 422
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482
Mailing Address - Country:US
Mailing Address - Phone:707-467-2000
Mailing Address - Fax:707-467-4999
Practice Address - Street 1:631 S ORCHARD AVE
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5011
Practice Address - Country:US
Practice Address - Phone:707-472-2922
Practice Address - Fax:707-467-4999
Is Sole Proprietor?:No
Enumeration Date:2013-10-10
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPCI304101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional