MEDICARE: ANGELA WILSON

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1851959266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA WILSON

Provider Business Mailing Address
First Line	:	1616 N CENTRAL AVE APT 1407
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85004-1660
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2111 E BASELINE RD STE C3
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85283-1521
Country	:	US
Telephone Number	:	602-540-3593
Fax Number	:

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

Provider Enumeration Date	:	05/31/2019
Last Update Date	:	05/31/2019

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Directions to “ ANGELA WILSON ” Practice Location

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