Individual
MRS. DIANE BROADY WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LPC
Contact information
Practice address
1411 E AMARILLO BLVD, 1411 AMARILLO BLVD., EAST, J.O. WYATT CLINIC, AMARILLO, TX 79107-5555
(806) 351-7212
(806) 351-7284
Mailing address
1411 E AMARILLO BLVD, 1411 AMARILLO BLVD., EAST, J.O. WYATT CLINIC, AMARILLO, TX 79107-5555
(806) 351-7212
(806) 351-7284
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
—
—
101YM0800X
Mental Health Counselor
Primary
16692
TX
101YP2500X
Professional Counselor
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
144810202
—
TX
Enumeration date
08/10/2006
Last updated
12/20/2011
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