Basic Information
| Provider Information | |||||||||
| NPI: | 1972931822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | RONALD | ||||||||
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| Credential: | LMHC # 39002496A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 W 3RD STREET | ||||||||
| Address2: | |||||||||
| City: | CONNERSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473312183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652881928 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 240 N TILLOTSON AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652881928 | ||||||||
| FaxNumber: | 7657410310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2013 | ||||||||
| LastUpdateDate: | 08/02/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 39002496A | IN | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 101Y00000X | 05 | IN | MEDICAID |