Provider Demographics
NPI:1548670433
Name:WILSON, STACEY (MED, BCBA)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8324 CEDAR CHASE DR
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-4030
Mailing Address - Country:US
Mailing Address - Phone:940-368-7105
Mailing Address - Fax:
Practice Address - Street 1:8324 CEDAR CHASE DR
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817-4030
Practice Address - Country:US
Practice Address - Phone:940-368-7105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-01
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-14-15649103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst