Provider Demographics
NPI:1245687797
Name:WILSON, JUSTIN (MENTAL HEALTH TECH)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:MENTAL HEALTH TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9211 N COUNCIL RD APT 140
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-1338
Mailing Address - Country:US
Mailing Address - Phone:405-429-9948
Mailing Address - Fax:
Practice Address - Street 1:4400 N LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-5104
Practice Address - Country:US
Practice Address - Phone:405-424-7711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-14
Last Update Date:2016-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist