Provider Demographics
NPI:1093537110
Name:WILSON, MAXWELL S
Entity type:Individual
Prefix:
First Name:MAXWELL
Middle Name:S
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 GRANITE DR
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-9784
Mailing Address - Country:US
Mailing Address - Phone:603-249-6551
Mailing Address - Fax:
Practice Address - Street 1:720 100 YEAR PARTY CT
Practice Address - Street 2:SUITE 200
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80504
Practice Address - Country:US
Practice Address - Phone:720-295-7427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health