Basic Information
| Provider Information | |||||||||
| NPI: | 1376705434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | EMMONS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MA LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 62 RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | LANDER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825209788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073304635 | ||||||||
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| Practice Location | |||||||||
| Address1: | 511NORTH 12TH ST | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078576685 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2008 | ||||||||
| LastUpdateDate: | 07/24/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | LMFT-111 | WY | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.