Healthcare Provider Details

I. General information

NPI: 1215175542
Provider Name (Legal Business Name): SUSAN CLEMENT WILSON MSC, MA, LGC, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2009
Last Update Date: 08/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 DULCE RD
SANTA FE NM
87508-8284
US

IV. Provider business mailing address

5 DULCE RD
SANTA FE NM
87508-8284
US

V. Phone/Fax

Practice location:
  • Phone: 505-577-8480
  • Fax: 505-466-2183
Mailing address:
  • Phone: 505-577-8480
  • Fax: 505-466-2183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0118861
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License NumberGC2009-012
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: