Healthcare Provider Details

I. General information

NPI: 1033510243
Provider Name (Legal Business Name): STANLEY WILSON M.A,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2014
Last Update Date: 09/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 BUSTER RDG
SANTA FE NM
87505-9594
US

IV. Provider business mailing address

8 BUSTER RDG
SANTA FE NM
87505-9594
US

V. Phone/Fax

Practice location:
  • Phone: 505-466-2156
  • Fax:
Mailing address:
  • Phone: 505-466-2156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberL.P.C.C.#2767
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: