Provider Demographics
NPI:1760408660
Name:WILSON, ADELAIDE CLEO (LMFT)
Entity Type:Individual
Prefix:
First Name:ADELAIDE
Middle Name:CLEO
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1876 S SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-6136
Mailing Address - Country:US
Mailing Address - Phone:307-672-0475
Mailing Address - Fax:307-672-0476
Practice Address - Street 1:63 N BURRITT AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:WY
Practice Address - Zip Code:82834-1868
Practice Address - Country:US
Practice Address - Phone:307-337-8247
Practice Address - Fax:307-278-0766
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY145106H00000X
MN1021106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY136274700Medicaid