Basic Information
| Provider Information | |||||||||
| NPI: | 1639848013 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | CARMEN | ||||||||
| MiddleName: | DOLORES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 627 NE EVANS ST | ||||||||
| Address2: | |||||||||
| City: | MCMINNVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971283923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034347523 | ||||||||
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| Practice Location | |||||||||
| Address1: | 433 NE 17TH ST APT 7 | ||||||||
| Address2: | |||||||||
| City: | MCMINNVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971283303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148123992 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2021 | ||||||||
| LastUpdateDate: | 07/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | OR | Y | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor |
No ID Information.