Provider Demographics
NPI:1740874536
Name:WILSON, CARMEN MARIE
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:MARIE
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:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:PILLAGER
Mailing Address - State:MN
Mailing Address - Zip Code:56473-0128
Mailing Address - Country:US
Mailing Address - Phone:507-720-7775
Mailing Address - Fax:
Practice Address - Street 1:725 CENTER AVE
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-1958
Practice Address - Country:US
Practice Address - Phone:507-720-7775
Practice Address - Fax:218-287-1267
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2467908163WA0400X
MN302876101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1444799OtherMN DHS