Provider Demographics
NPI:1497353049
Name:WILSON, ANGELA CHRISTENE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:CHRISTENE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2523 E 88TH ST APT 315
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-2423
Mailing Address - Country:US
Mailing Address - Phone:918-497-9407
Mailing Address - Fax:
Practice Address - Street 1:2523 E 88TH ST APT 315
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-2423
Practice Address - Country:US
Practice Address - Phone:918-497-9407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103K00000X, 106E00000X, 106S00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician