Provider Demographics
NPI:1659032191
Name:WILSON, ANGELA PRINCESS
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:PRINCESS
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 1:1290 CHAMBERS RD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80011-7117
Mailing Address - Country:US
Mailing Address - Phone:303-617-2300
Mailing Address - Fax:
Practice Address - Street 1:791 CHAMBERS RD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-7112
Practice Address - Country:US
Practice Address - Phone:303-617-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-06
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO101YM0800X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO943461112Medicaid