Provider Demographics
NPI:1083328009
Name:WILSON, MELANIE A
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N SIDNEY AVE
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-4383
Mailing Address - Country:US
Mailing Address - Phone:479-890-5494
Mailing Address - Fax:479-498-9665
Practice Address - Street 1:301 N SIDNEY AVE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-4383
Practice Address - Country:US
Practice Address - Phone:479-890-5494
Practice Address - Fax:479-498-9665
Is Sole Proprietor?:No
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARRBT-22-247300106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician