Healthcare Provider Details

I. General information

NPI: 1790831931
Provider Name (Legal Business Name): MELINDA J. WILSON MELINDA J. WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MELINDA J. COLBURN ED.S.

II. Dates (important events)

Enumeration Date: 01/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E MESQUITE ST
GILBERT AZ
85296-1814
US

IV. Provider business mailing address

5808 E BROWN RD #118
MESA AZ
85205-4437
US

V. Phone/Fax

Practice location:
  • Phone: 480-813-1240
  • Fax: 480-813-7387
Mailing address:
  • Phone: 480-282-3530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: