Healthcare Provider Details

I. General information

NPI: 1003524612
Provider Name (Legal Business Name): DANIEL HENRIE WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2022
Last Update Date: 11/11/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7220 W JEFFERSON AVE STE 202
LAKEWOOD CO
80235-2023
US

IV. Provider business mailing address

3363 ECCLES AVE
OGDEN UT
84403-1213
US

V. Phone/Fax

Practice location:
  • Phone: 303-225-7673
  • Fax:
Mailing address:
  • Phone: 801-791-8195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: