MEDICARE: HOLLAND WILSON LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	130	WY

General Provider Information

NPI Number	:	1245471846
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLAND WILSON LMFT

Provider Business Mailing Address
First Line	:	PO BOX 3850
Second Line	:
City	:	ALPINE
State	:	WY
Zip	:	83128-3841
Country	:	US
Telephone Number	:	307-248-1497
Fax Number	:	307-224-4973

Provider Business Practice Location Address
First Line	:	310 E BROADWAY AVE
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001-8636
Country	:	US
Telephone Number	:	307-654-7003
Fax Number	:	307-224-4973

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/12/2009
Last Update Date	:	03/02/2016

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Directions to “ HOLLAND WILSON LMFT” Practice Location

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