=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497104103
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANN WILSON, PSY.D. PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2016
-----------------------------------------------------
Last Update Date | 01/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2901 WILCREST DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77042-3399
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-300-0713
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 173
-----------------------------------------------------
City | JEROME
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86331-0173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-919-5732
-----------------------------------------------------
Fax | 832-583-0012
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ANN MARIE WILSON
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 832-919-5732
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 36477
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------