Provider Demographics
NPI:1255524047
Name:WILSON, JOHN M (MA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:M
Last Name:WILSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9362 TEDDY LN STE 206
Mailing Address - Street 2:
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-2871
Mailing Address - Country:US
Mailing Address - Phone:720-838-0450
Mailing Address - Fax:303-705-8039
Practice Address - Street 1:9362 TEDDY LN STE 206
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-2871
Practice Address - Country:US
Practice Address - Phone:303-891-4891
Practice Address - Fax:303-705-8039
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1350101YA0400X, 101YP2500X
CO3892101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)