Healthcare Provider Details

I. General information

NPI: 1104763564
Provider Name (Legal Business Name): MAX WILSON COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1022 SANTA CLARA DR
SANTA FE NM
87507-5136
US

IV. Provider business mailing address

1022 SANTA CLARA DR
SANTA FE NM
87507-5136
US

V. Phone/Fax

Practice location:
  • Phone: 971-712-3307
  • Fax:
Mailing address:
  • Phone: 971-712-3307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MAX E WILSON
Title or Position: LMFT
Credential: LMFT
Phone: 971-712-3307