Healthcare Provider Details

I. General information

NPI: 1154279966
Provider Name (Legal Business Name): EBONY DENISE CARTER WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2026
Last Update Date: 03/18/2026
Certification Date: 03/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 NORTH SOUTH FE AVENU,FOUNTAIN ,CO 80817
COLORADO SPRINGS CO
80817
US

IV. Provider business mailing address

901 NORTH SOUTH FE AVENUE,FOUNTAIN ,CO 80817
COLORADO SPRINGS CO
80817
US

V. Phone/Fax

Practice location:
  • Phone: 719-362-5219
  • Fax:
Mailing address:
  • Phone: 719-362-5219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number10507320
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: