Basic Information
| Provider Information | |||||||||
| NPI: | 1972136984 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1035 W GLEN OAKS LN STE 110 | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530923392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622446178 | ||||||||
| FaxNumber: | 2622993040 | ||||||||
| Practice Location | |||||||||
| Address1: | 17100 W NORTH AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530054436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622446177 | ||||||||
| FaxNumber: | 2622993040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2020 | ||||||||
| LastUpdateDate: | 07/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 8641-225 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 4566-226 | WI | N | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.