Provider Demographics
NPI:1265822209
Name:WILSON, PATCHES S
Entity Type:Individual
Prefix:
First Name:PATCHES
Middle Name:S
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:PO BOX 61
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:OK
Mailing Address - Zip Code:74743-0061
Mailing Address - Country:US
Mailing Address - Phone:580-326-2200
Mailing Address - Fax:580-326-2201
Practice Address - Street 1:612 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-4025
Practice Address - Country:US
Practice Address - Phone:580-326-2200
Practice Address - Fax:580-326-2201
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker