Provider Demographics
NPI:1235547829
Name:WILSON, HEATHER RENE (BS, BCABA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:RENE
Last Name:WILSON
Suffix:
Gender:F
Credentials:BS, BCABA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:RENE WILSON
Other - Last Name:PALMISANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:2123 W 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-4803
Mailing Address - Country:US
Mailing Address - Phone:813-293-4536
Mailing Address - Fax:
Practice Address - Street 1:2123 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-4803
Practice Address - Country:US
Practice Address - Phone:813-293-4536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-27
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-24-71476103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst