Healthcare Provider Details

I. General information

NPI: 1215238514
Provider Name (Legal Business Name): MRS. TONYA DAILWAYNE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2010
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4016 S.E. 24TH STREET
DEL CITY OK
73115
US

IV. Provider business mailing address

4016 SE 24TH ST
DEL CITY OK
73115-2526
US

V. Phone/Fax

Practice location:
  • Phone: 479-619-6296
  • Fax:
Mailing address:
  • Phone: 479-619-6296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: