Provider Demographics
NPI:1790831931
Name:J. WILSON, MELINDA (MELINDA J WILSON)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:J. WILSON
Suffix:
Gender:F
Credentials:MELINDA J WILSON
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:
Other - Last Name:J. COLBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDS
Mailing Address - Street 1:5808 E BROWN RD
Mailing Address - Street 2:#118
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-4437
Mailing Address - Country:US
Mailing Address - Phone:480-282-3530
Mailing Address - Fax:
Practice Address - Street 1:1000 E MESQUITE ST
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-1814
Practice Address - Country:US
Practice Address - Phone:480-813-1240
Practice Address - Fax:480-813-7387
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool