Provider Demographics
NPI:1295182871
Name:WILSON, KARRIE
Entity Type:Individual
Prefix:
First Name:KARRIE
Middle Name:
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 1:2979 ALLIED ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5567
Mailing Address - Country:US
Mailing Address - Phone:920-337-6740
Mailing Address - Fax:
Practice Address - Street 1:2979 ALLIED ST
Practice Address - Street 2:SUITE C
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5567
Practice Address - Country:US
Practice Address - Phone:920-337-6740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17792-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)