Basic Information
| Provider Information | |||||||||
| NPI: | 1245672609 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | JAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 28 3/4 RD | ||||||||
| Address2: | BLDG A | ||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815015016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706837107 | ||||||||
| FaxNumber: | 9706837167 | ||||||||
| Practice Location | |||||||||
| Address1: | 267 6TH ST | ||||||||
| Address2: | |||||||||
| City: | MEEKER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708785112 | ||||||||
| FaxNumber: | 9708784315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2013 | ||||||||
| LastUpdateDate: | 07/25/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.