Provider Demographics
NPI:1073090700
Name:WILSON, SCOTT ALAN
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:ALAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15724 E KIM DR
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-1800
Mailing Address - Country:US
Mailing Address - Phone:480-862-9887
Mailing Address - Fax:
Practice Address - Street 1:5010 E SHEA BLVD STE D202
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-4570
Practice Address - Country:US
Practice Address - Phone:602-569-4328
Practice Address - Fax:602-569-4378
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling