Provider Demographics
NPI:1083304695
Name:WILSON, KLARYSA MARIAH (RBT-23-272664)
Entity Type:Individual
Prefix:
First Name:KLARYSA
Middle Name:MARIAH
Last Name:WILSON
Suffix:
Gender:F
Credentials:RBT-23-272664
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 CARSON HL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-5500
Mailing Address - Country:US
Mailing Address - Phone:210-634-1129
Mailing Address - Fax:
Practice Address - Street 1:419 CARSON HL
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-5500
Practice Address - Country:US
Practice Address - Phone:210-634-1129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-23-272664106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician