Provider Demographics
NPI:1912027764
Name:WILSON, EVELYN (FP)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:FP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 E INDIAN WELLS PL
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-6957
Mailing Address - Country:US
Mailing Address - Phone:480-275-5555
Mailing Address - Fax:
Practice Address - Street 1:890 E INDIAN WELLS PL
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85249-6957
Practice Address - Country:US
Practice Address - Phone:480-275-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ989585Medicare ID - Type Unspecified