Basic Information
| Provider Information | |||||||||
| NPI: | 1316383540 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | MADELEINE | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 BROADWAY NE | ||||||||
| Address2: | NM SOLUTIONS | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871022360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052680701 | ||||||||
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| Practice Location | |||||||||
| Address1: | 707 BROADWAY NE | ||||||||
| Address2: | NM SOLUTIONS | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871022360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052680701 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2013 | ||||||||
| LastUpdateDate: | 05/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | M-08817 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 39773248 | 05 | NM | MEDICAID |