Provider Demographics
NPI:1790908697
Name:WILSON, CAROLYN MARIE
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MARIE
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 1:5315 E MARSHALL PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74115-5587
Mailing Address - Country:US
Mailing Address - Phone:918-361-6770
Mailing Address - Fax:
Practice Address - Street 1:2325 S HARVARD AVE
Practice Address - Street 2:STE 500
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-3300
Practice Address - Country:US
Practice Address - Phone:918-712-4301
Practice Address - Fax:918-712-3409
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health