Provider Demographics
NPI:1033510243
Name:WILSON, STANLEY (MA,)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:MA,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 BUSTER RDG
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-9594
Mailing Address - Country:US
Mailing Address - Phone:505-466-2156
Mailing Address - Fax:
Practice Address - Street 1:8 BUSTER RDG
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-9594
Practice Address - Country:US
Practice Address - Phone:505-466-2156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-07
Last Update Date:2014-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NML.P.C.C.#2767101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional