Provider Demographics
NPI:1548625825
Name:WILSON, SOMOVA
Entity type:Individual
Prefix:
First Name:SOMOVA
Middle Name:
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 1:7008 WOODWICK DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75232-3534
Mailing Address - Country:US
Mailing Address - Phone:469-387-9761
Mailing Address - Fax:
Practice Address - Street 1:6316 FOREST KNOLL TRL
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75232-3110
Practice Address - Country:US
Practice Address - Phone:469-387-9761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX141051171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator