Provider Demographics
NPI:1891907572
Name:WILSON, MARY DAWN (CT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:DAWN
Last Name:WILSON
Suffix:
Gender:F
Credentials:CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7
Mailing Address - Street 2:100 WIESNER RD
Mailing Address - City:SHUNGNAK
Mailing Address - State:AK
Mailing Address - Zip Code:99773
Mailing Address - Country:US
Mailing Address - Phone:907-437-2002
Mailing Address - Fax:907-437-2004
Practice Address - Street 1:436 5TH ST TED STEVENS WAY
Practice Address - Street 2:
Practice Address - City:KOTZEBUE
Practice Address - State:AK
Practice Address - Zip Code:99752
Practice Address - Country:US
Practice Address - Phone:907-437-2002
Practice Address - Fax:907-437-2004
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor