Healthcare Provider Details

I. General information

NPI: 1316611239
Provider Name (Legal Business Name): CAROLYN DENISE WILSON LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 BERTHA RD
TAOS NM
87571-7148
US

IV. Provider business mailing address

176 MAESTAS RD UNIT B
RANCHOS DE TAOS NM
87557-9779
US

V. Phone/Fax

Practice location:
  • Phone: 401-323-1432
  • Fax:
Mailing address:
  • Phone: 401-323-1432
  • 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: