Healthcare Provider Details

I. General information

NPI: 1154692812
Provider Name (Legal Business Name): MS. LAUREN WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1318 ALVIOLA AVE
OKLAHOMA CITY OK
73110-1402
US

IV. Provider business mailing address

1318 ALVIOLA AVE
OKLAHOMA CITY OK
73110-1402
US

V. Phone/Fax

Practice location:
  • Phone: 405-863-0433
  • Fax:
Mailing address:
  • Phone: 405-863-0433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: