Basic Information
| Provider Information | |||||||||
| NPI: | 1124508700 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCPC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 271 W 3RD ST N STE 600 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672021223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166607600 | ||||||||
| FaxNumber: | 3169415075 | ||||||||
| Practice Location | |||||||||
| Address1: | 271 W 3RD ST N STE 600 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672021223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166607600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2018 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 3274 | KS | N | Behavioral Health & Social Service Providers | Social Worker | 101YP2500X | 3335 | KS | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 03361 | KS | N | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.