Provider Demographics
NPI:1407513492
Name:WILSON, CONNOR T (RBT)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:T
Last Name:WILSON
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3090 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2117
Mailing Address - Country:US
Mailing Address - Phone:484-883-7998
Mailing Address - Fax:
Practice Address - Street 1:2285 FREMONT DR
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2533
Practice Address - Country:US
Practice Address - Phone:719-425-7771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-24
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician