Provider Demographics
NPI:1447770086
Name:WILSON, CHARLES LYNN JR (MS)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:LYNN
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1402 N FLORENCE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-3159
Mailing Address - Country:US
Mailing Address - Phone:186-080-3809
Mailing Address - Fax:209-425-5727
Practice Address - Street 1:1402 N FLORENCE AVE STE B
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-3159
Practice Address - Country:US
Practice Address - Phone:918-608-0380
Practice Address - Fax:209-425-5727
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-25
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK10690101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health