MEDICARE: CHARLENE WILTS

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1932741873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLENE WILTS

Provider Business Mailing Address
First Line	:	475 OXFORD DRIVE SUITE 104
Second Line	:
City	:	NEW BRAUNFELS
State	:	TX
Zip	:	78130
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	475 OXFORD DRIVE SUITE 104
Second Line	:
City	:	NEW BRAUNFELS
State	:	TX
Zip	:	78130-7813
Country	:	US
Telephone Number	:	830-268-4236
Fax Number	:

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

Provider Enumeration Date	:	10/11/2019
Last Update Date	:	10/11/2019

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