Provider Demographics
NPI:1871209569
Name:WILSON, JULIE ANN
Entity type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86B MARTIN LN
Mailing Address - Street 2:
Mailing Address - City:MORIARTY
Mailing Address - State:NM
Mailing Address - Zip Code:87035-5605
Mailing Address - Country:US
Mailing Address - Phone:505-659-8721
Mailing Address - Fax:
Practice Address - Street 1:86B MARTIN LN
Practice Address - Street 2:
Practice Address - City:MORIARTY
Practice Address - State:NM
Practice Address - Zip Code:87035-5605
Practice Address - Country:US
Practice Address - Phone:505-659-8721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM99999OtherLMHC