Provider Demographics
NPI:1154672780
Name:WILSON, MARQUITA RENEE
Entity Type:Individual
Prefix:
First Name:MARQUITA
Middle Name:RENEE
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 1:2417 E 48TH ST N
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74130-2017
Mailing Address - Country:US
Mailing Address - Phone:918-636-4165
Mailing Address - Fax:
Practice Address - Street 1:1 W 36TH ST N
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-1700
Practice Address - Country:US
Practice Address - Phone:918-636-4165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-22
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid