Provider Demographics
NPI:1649863721
Name:WILSON, CODY L
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:L
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 1:25335 BUDDE RD APT 921
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77380-2319
Mailing Address - Country:US
Mailing Address - Phone:936-222-1175
Mailing Address - Fax:
Practice Address - Street 1:5452 HIGHWAY 105 W STE 103
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-1403
Practice Address - Country:US
Practice Address - Phone:936-520-9124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX81173101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health