Provider Demographics
NPI:1356629687
Name:WILSON, MARY
Entity Type:Individual
Prefix:
First Name:MARY
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 1:780 E COUNTRY PLACE RD
Mailing Address - Street 2:
Mailing Address - City:PAHRUMP
Mailing Address - State:NV
Mailing Address - Zip Code:89060-1705
Mailing Address - Country:US
Mailing Address - Phone:775-910-1736
Mailing Address - Fax:
Practice Address - Street 1:1601 E BASIN AVE
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89060-4611
Practice Address - Country:US
Practice Address - Phone:775-910-1736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-03
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
NVC10404101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner