MEDICARE: MR. WESLEY ROWLAND WILSON LMFT, LAC, AAMFT SUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	ACD -272	CO
2	106H00000X	Marriage & Family Therapist	922	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ACD -272	OTHER	CO	DORA, DEPT. OF REGULATED AGENDIES
2	MFT-922	OTHER	CO	DORA, DEPT. OF REGULATED AGENDIES

General Provider Information

NPI Number	:	1588814529
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WESLEY ROWLAND WILSON LMFT, LAC, AAMFT SUP

Provider Business Mailing Address
First Line	:	2515 KINDERHOOK LN
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-3870
Country	:	US
Telephone Number	:	719-331-3338
Fax Number	:	719-599-9001

Provider Business Practice Location Address
First Line	:	2515 KINDERHOOK LN
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-3870
Country	:	US
Telephone Number	:	719-331-3338
Fax Number	:	719-599-9001

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2008
Last Update Date	:	11/20/2022

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