Individual
DOMINIQUE MARIE WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MA, LCPC, CRC
Contact information
Practice address
785 WALL ST # 200, O FALLON, IL 62269-1959
(618) 367-2194
Mailing address
1109 HIGH VALLEY LN, BELLEVILLE, IL 62221-6846
(317) 900-6556
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
CI0365
NV
101YM0800X
Mental Health Counselor
CI0365
NV
101YP2500X
Professional Counselor
Primary
180.012945
IL
Other
Enumeration date
05/08/2018
Last updated
08/11/2020
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