Provider Demographics
NPI:1487463329
Name:WILSON, WESLEY (LFMT)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:LFMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:QUARRYVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17566-1268
Mailing Address - Country:US
Mailing Address - Phone:717-806-5050
Mailing Address - Fax:717-806-5179
Practice Address - Street 1:215 E STATE ST
Practice Address - Street 2:
Practice Address - City:QUARRYVILLE
Practice Address - State:PA
Practice Address - Zip Code:17566-1268
Practice Address - Country:US
Practice Address - Phone:717-806-5050
Practice Address - Fax:717-806-5179
Is Sole Proprietor?:No
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMF001688106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist