Provider Demographics
NPI:1417531898
Name:WILSON, COLLEEN (RBT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2871 N TALLEY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-9169
Mailing Address - Country:US
Mailing Address - Phone:812-344-3885
Mailing Address - Fax:
Practice Address - Street 1:120 W JACKSON ST STE B&C
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-1295
Practice Address - Country:US
Practice Address - Phone:317-512-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-20-133651106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician