MEDICARE: MR. IAN GLEN WILSON MA, BCBA

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	103K00000X	Behavior Analyst	1-08-4578	CA

General Provider Information

NPI Number	:	1568781615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. IAN GLEN WILSON MA, BCBA

Provider Business Mailing Address
First Line	:	6400 TUPELO DR
Second Line	:
City	:	CITRUS HEIGHTS
State	:	CA
Zip	:	95621-1741
Country	:	US
Telephone Number	:	916-729-3098
Fax Number	:	916-729-3006

Provider Business Practice Location Address
First Line	:	6400 TUPELO DR
Second Line	:
City	:	CITRUS HEIGHTS
State	:	CA
Zip	:	95621-1741
Country	:	US
Telephone Number	:	916-729-3098
Fax Number	:	916-729-3006

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

Provider Enumeration Date	:	05/27/2010
Last Update Date	:	05/27/2010

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