Healthcare Provider Details

I. General information

NPI: 1134798549
Provider Name (Legal Business Name): CHARLIZE BRIELLE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 W 400 S
SALT LAKE CITY UT
84101-1916
US

IV. Provider business mailing address

117 W 400 S
SALT LAKE CITY UT
84101-1916
US

V. Phone/Fax

Practice location:
  • Phone: 801-428-4257
  • Fax:
Mailing address:
  • Phone: 385-200-0110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14239643-6009
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: