Healthcare Provider Details

I. General information

NPI: 1316504210
Provider Name (Legal Business Name): DANIEL WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2019
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7220 W JEFFERSON AVE STE 100
LAKEWOOD CO
80235-2015
US

IV. Provider business mailing address

10260 WASHINGTON ST APT 1822
THORNTON CO
80229-2067
US

V. Phone/Fax

Practice location:
  • Phone: 303-225-7673
  • Fax: 866-283-0595
Mailing address:
  • Phone: 304-617-5336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-50464
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-20-40921
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: