Basic Information
| Provider Information | |||||||||
| NPI: | 1548548670 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | MADELON | ||||||||
| MiddleName: | ELEY | ||||||||
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| Credential: | PSYD, LPC | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WATT | ||||||||
| OtherFirstName: | MADELON | ||||||||
| OtherMiddleName: | ELEY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 220 RUSKIN DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809102522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195726100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 875 W MORENO AVE | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809051731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195726200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2011 | ||||||||
| LastUpdateDate: | 03/14/2016 | ||||||||
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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 | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | LPC.0012324 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.