Basic Information
| Provider Information | |||||||||
| NPI: | 1922390947 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | LONNIS | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 ALDERSGATE RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016610720 | ||||||||
| FaxNumber: | 5013257938 | ||||||||
| Practice Location | |||||||||
| Address1: | 2002 S FILLMORE ST | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722044909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019064938 | ||||||||
| FaxNumber: | 5014210175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | P1408055 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 203359795 | 05 | AR | MEDICAID |