Provider Demographics
NPI:1891273595
Name:WILSON, CASSANDRA JANE
Entity Type:Individual
Prefix:MRS
First Name:CASSANDRA
Middle Name:JANE
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 1:367 N DINNER BELL DR
Mailing Address - Street 2:
Mailing Address - City:CALHAN
Mailing Address - State:CO
Mailing Address - Zip Code:80808-8738
Mailing Address - Country:US
Mailing Address - Phone:720-935-9733
Mailing Address - Fax:
Practice Address - Street 1:7150 CAMPUS DR STE 160
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3178
Practice Address - Country:US
Practice Address - Phone:719-538-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-18-62187106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty