Provider Demographics
NPI:1740221993
Name:WILSON, MARTA A T (MFT, CPC, LCADC)
Entity Type:Individual
Prefix:
First Name:MARTA
Middle Name:A T
Last Name:WILSON
Suffix:
Gender:F
Credentials:MFT, CPC, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6375 W CHARLESTON BLVD
Mailing Address - Street 2:STE. A-100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-1139
Mailing Address - Country:US
Mailing Address - Phone:702-253-0818
Mailing Address - Fax:
Practice Address - Street 1:6375 W CHARLESTON BLVD
Practice Address - Street 2:STE. A-172
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-1139
Practice Address - Country:US
Practice Address - Phone:702-877-0684
Practice Address - Fax:702-877-0684
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV01035106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100508688Medicaid