Healthcare Provider Details

I. General information

NPI: 1588328298
Provider Name (Legal Business Name): HARRIET DEANDRA WILSON CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2021
Last Update Date: 10/04/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13201 NORTHWEST FREEWAY FAIRBANKS/NORTHWEST CROSSING SUITE 800
HOUSTON TX
77040
US

IV. Provider business mailing address

13201 NORTHWEST FREEWAY FAIRBANKS/NORTHWEST CROSSING SUITE 800
HOUSTON TX
77040
US

V. Phone/Fax

Practice location:
  • Phone: 832-952-7566
  • Fax:
Mailing address:
  • Phone: 832-952-7566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number81452
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: