Provider Demographics
NPI:1477170801
Name:WILSON, HAILEY ELEEN
Entity type:Individual
Prefix:
First Name:HAILEY
Middle Name:ELEEN
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 1:228 WINDING WAY
Mailing Address - Street 2:
Mailing Address - City:BRACEY
Mailing Address - State:VA
Mailing Address - Zip Code:23919-2098
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5575 S DURANGO DR #102
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113
Practice Address - Country:US
Practice Address - Phone:702-789-6877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-01
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
VA0906013226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician