Healthcare Provider Details

I. General information

NPI: 1275306169
Provider Name (Legal Business Name): LYDIA WILSON MS, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2023
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3025 FOUNTAIN DR
CONWAY AR
72034-3689
US

IV. Provider business mailing address

2370 APPLE BLOSSOM LN
CONWAY AR
72034-8452
US

V. Phone/Fax

Practice location:
  • Phone: 501-269-1656
  • Fax:
Mailing address:
  • Phone: 501-672-6348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: