Healthcare Provider Details

I. General information

NPI: 1538490776
Provider Name (Legal Business Name): MARY HAYDEN WILSON BSW,
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2010
Last Update Date: 11/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5828 MARIA DEL MAR ST
LAS VEGAS NV
89130-7299
US

IV. Provider business mailing address

5828 MARIA DEL MAR ST
LAS VEGAS NV
89130-7299
US

V. Phone/Fax

Practice location:
  • Phone: 702-578-6779
  • Fax: 702-925-4775
Mailing address:
  • Phone: 702-578-6779
  • Fax: 702-925-4775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: