Healthcare Provider Details

I. General information

NPI: 1073221578
Provider Name (Legal Business Name): ANNA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W BROADWAY STE 2F
COLUMBIA MO
65203-3842
US

IV. Provider business mailing address

201 W BROADWAY STE 2F
COLUMBIA MO
65203-3842
US

V. Phone/Fax

Practice location:
  • Phone: 573-214-0436
  • Fax:
Mailing address:
  • Phone: 573-214-0436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: