Individual
MR. KEITH L WILSON III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MS, LPC
Contact information
Practice address
1330 E CHERRY ST # 12, SPRINGFIELD, MO 65802-3429
(417) 761-9598
Mailing address
1330 E CHERRY ST # 12, SPRINGFIELD, MO 65802-3429
(417) 761-9598
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
2012037415
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1801285440
—
MO
05
—
1982949988
—
MO
Enumeration date
12/01/2012
Last updated
02/17/2015
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