Provider Demographics
NPI:1245576669
Name:WILSON, GLORIA J (BHRS)
Entity Type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 CALLAHAN DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73121-1850
Mailing Address - Country:US
Mailing Address - Phone:405-424-5111
Mailing Address - Fax:
Practice Address - Street 1:4501 CALLAHAN DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73121-1850
Practice Address - Country:US
Practice Address - Phone:405-424-5111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-13
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional