Healthcare Provider Details

I. General information

NPI: 1831770304
Provider Name (Legal Business Name): TAYLER RENEE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2021
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N BRYANT AVE STE A6
EDMOND OK
73034-6300
US

IV. Provider business mailing address

11216 NW 135TH ST
YUKON OK
73099-9475
US

V. Phone/Fax

Practice location:
  • Phone: 572-239-9500
  • Fax:
Mailing address:
  • Phone: 918-644-8201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10261
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: