Provider Demographics
NPI:1467942276
Name:WILSON, CAROLYN (BCBA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4519 GREENFIELD DR
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-9480
Mailing Address - Country:US
Mailing Address - Phone:931-261-0889
Mailing Address - Fax:
Practice Address - Street 1:4519 GREENFIELD DR
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-9480
Practice Address - Country:US
Practice Address - Phone:931-261-0889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18-32323103K00000X
18-32323103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-17-32048OtherBACB