Provider Demographics
NPI:1326593872
Name:WILSON, LINDA M C
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:M C
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 1:299 E 3450 N
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-4515
Mailing Address - Country:US
Mailing Address - Phone:801-473-5518
Mailing Address - Fax:
Practice Address - Street 1:1190 N 900 E
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3536
Practice Address - Country:US
Practice Address - Phone:801-422-7620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker