Provider Demographics
NPI:1528464856
Name:WILSON, EMILY B (MA)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:B
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 N HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-2310
Mailing Address - Country:US
Mailing Address - Phone:720-513-6156
Mailing Address - Fax:
Practice Address - Street 1:104 N HARRISON AVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-2310
Practice Address - Country:US
Practice Address - Phone:720-513-6156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-13
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0013186101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COLPC.0013186OtherCOLORADO DEPARTMENT OF REGULATORY AGENCIES