Healthcare Provider Details

I. General information

NPI: 1154139913
Provider Name (Legal Business Name): EVAN WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2024
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5181 WARD RD UNIT 206
WHEAT RIDGE CO
80033-1925
US

IV. Provider business mailing address

207 W SIMPSON ST
LAFAYETTE CO
80026-1658
US

V. Phone/Fax

Practice location:
  • Phone: 720-724-6813
  • Fax:
Mailing address:
  • Phone: 617-733-2345
  • Fax: 617-733-2345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCC.0024939
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: