MEDICARE: MR. JAMES VERNON WILSON M.A., L.I.S.A.C.

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	11800	AZ

General Provider Information

NPI Number	:	1689847386
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES VERNON WILSON M.A., L.I.S.A.C.

Provider Business Mailing Address
First Line	:	2123 W CHAMBERS ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-3720
Country	:	US
Telephone Number	:	602-276-5653
Fax Number	:

Provider Business Practice Location Address
First Line	:	2123 W CHAMBERS ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-3720
Country	:	US
Telephone Number	:	602-276-5653
Fax Number	:

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

Provider Enumeration Date	:	04/02/2008
Last Update Date	:	04/02/2008

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