Provider Demographics
NPI:1952916819
Name:WILSON, TARRA LYNN (RBT)
Entity Type:Individual
Prefix:
First Name:TARRA
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:817 S ELM PL STE 104
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-5369
Mailing Address - Country:US
Mailing Address - Phone:918-928-5437
Mailing Address - Fax:888-720-8944
Practice Address - Street 1:817 S ELM PL STE 104
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-5369
Practice Address - Country:US
Practice Address - Phone:918-928-5437
Practice Address - Fax:888-720-8944
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician