Basic Information
| Provider Information | |||||||||
| NPI: | 1538344908 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | DWIGHT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LMHP, LADC, CPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3300 N 60TH ST | ||||||||
| Address2: | CATHOLIC CHARITIES | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681043402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025540520 | ||||||||
| FaxNumber: | 4025518797 | ||||||||
| Practice Location | |||||||||
| Address1: | 3020 18TH ST SUITE 17 | ||||||||
| Address2: | CATHOLIC CHARITIES | ||||||||
| City: | COLUMBUS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 686014254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025633833 | ||||||||
| FaxNumber: | 4025628714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2008 | ||||||||
| LastUpdateDate: | 05/09/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 819 | NE | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 1770 | NE | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | 3523 | NE | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.