Basic Information
| Provider Information | |||||||||
| NPI: | 1306959077 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | C.M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4825 BISMARC DR | ||||||||
| Address2: | |||||||||
| City: | DEL CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731154413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052088753 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 804 W CHOCTAW AVE | ||||||||
| Address2: | |||||||||
| City: | CHICKASHA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730182310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052220622 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.