Healthcare Provider Details

I. General information

NPI: 1790029676
Provider Name (Legal Business Name): ALICE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2012
Last Update Date: 11/26/2025
Certification Date: 11/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4285 N RANCHO DR STE 130
LAS VEGAS NV
89130-3455
US

IV. Provider business mailing address

4285 N RANCHO DR STE 130
LAS VEGAS NV
89130-3455
US

V. Phone/Fax

Practice location:
  • Phone: 702-385-5331
  • Fax: 419-932-6232
Mailing address:
  • Phone: 702-385-5331
  • Fax: 419-932-6232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCI5187
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: