Healthcare Provider Details

I. General information

NPI: 1760408660
Provider Name (Legal Business Name): ADELAIDE CLEO WILSON LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 N BURRITT AVE
BUFFALO WY
82834-1868
US

IV. Provider business mailing address

1876 S SHERIDAN AVE
SHERIDAN WY
82801-6136
US

V. Phone/Fax

Practice location:
  • Phone: 307-337-8247
  • Fax: 307-278-0766
Mailing address:
  • Phone: 307-672-0475
  • Fax: 307-672-0476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number145
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: