Provider Demographics
NPI:1508150350
Name:WILSON, POLLY
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:
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 1:2502 CROSSROADS DR
Mailing Address - Street 2:B
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-2503
Mailing Address - Country:US
Mailing Address - Phone:580-226-4800
Mailing Address - Fax:
Practice Address - Street 1:2502 CROSSROADS DR
Practice Address - Street 2:B
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-2503
Practice Address - Country:US
Practice Address - Phone:580-226-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1582101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional