Healthcare Provider Details

I. General information

NPI: 1275768285
Provider Name (Legal Business Name): HEIDI WILSON MBA, MA, LPC, CACII
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 05/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1137 PEARL ST SUITE 207
BOULDER CO
80302-5159
US

IV. Provider business mailing address

1630 30TH ST STE A PMB 217
BOULDER CO
80301-1045
US

V. Phone/Fax

Practice location:
  • Phone: 720-530-8227
  • Fax: 303-927-6016
Mailing address:
  • Phone: 720-530-8227
  • Fax: 303-927-6016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6191
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4075
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: