Provider Demographics
NPI:1568739118
Name:WILSON, GRACE ANN (PHD, LMFT)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:SUITE 280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:405-951-2855
Mailing Address - Fax:405-951-2858
Practice Address - Street 1:3500 NW 56TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4529
Practice Address - Country:US
Practice Address - Phone:405-951-2855
Practice Address - Fax:405-951-2858
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7088A106H00000X
OK1169106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist