Provider Demographics
NPI:1720374614
Name:WILSON, MARTHA JANE (LBP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:JANE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LBP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 673
Mailing Address - Street 2:
Mailing Address - City:VALLIANT
Mailing Address - State:OK
Mailing Address - Zip Code:74764-0673
Mailing Address - Country:US
Mailing Address - Phone:580-933-7031
Mailing Address - Fax:580-933-7034
Practice Address - Street 1:300 N DALTON AVE
Practice Address - Street 2:
Practice Address - City:VALLIANT
Practice Address - State:OK
Practice Address - Zip Code:74764-0673
Practice Address - Country:US
Practice Address - Phone:580-933-7031
Practice Address - Fax:580-933-7034
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0277101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor