Provider Demographics
NPI:1508511882
Name:WILSON, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
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 1:239 WILLOWBROOK LN
Mailing Address - Street 2:
Mailing Address - City:WHITEHOUSE
Mailing Address - State:TX
Mailing Address - Zip Code:75791-3499
Mailing Address - Country:US
Mailing Address - Phone:903-363-6094
Mailing Address - Fax:
Practice Address - Street 1:1800 SHILOH RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-2418
Practice Address - Country:US
Practice Address - Phone:903-714-8610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106360104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker