Provider Demographics
NPI:1326379819
Name:WILSON, BRENDA JOYCE (BHRS)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:JOYCE
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 1:30 C ST NE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-6316
Mailing Address - Country:US
Mailing Address - Phone:918-540-1563
Mailing Address - Fax:918-542-7778
Practice Address - Street 1:30 C STREET N. E.
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-3361
Practice Address - Country:US
Practice Address - Phone:918-540-1563
Practice Address - Fax:918-542-7778
Is Sole Proprietor?:No
Enumeration Date:2010-01-22
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100732380CMedicaid