Provider Demographics
NPI:1376705434
Name:WILSON, CHARLES EMMONS (MA LMFT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EMMONS
Last Name:WILSON
Suffix:
Gender:M
Credentials:MA LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-9788
Mailing Address - Country:US
Mailing Address - Phone:307-330-4635
Mailing Address - Fax:
Practice Address - Street 1:511NORTH 12TH ST
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501
Practice Address - Country:US
Practice Address - Phone:307-857-6685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLMFT-111106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist