Healthcare Provider Details

I. General information

NPI: 1245557958
Provider Name (Legal Business Name): HOLLY K WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2010
Last Update Date: 04/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 SUNSET LOOP
MESCALERO NM
88340
US

IV. Provider business mailing address

PO BOX 228
MESCALERO NM
88340-0228
US

V. Phone/Fax

Practice location:
  • Phone: 575-464-4338
  • Fax: 575-464-4331
Mailing address:
  • Phone: 575-464-4338
  • Fax: 575-464-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0119501
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: