Basic Information
| Provider Information | |||||||||
| NPI: | 1568739118 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHD, LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5300 N INDEPENDENCE AVE | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731125556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059512855 | ||||||||
| FaxNumber: | 4059512858 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 NW 56TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731124529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059512855 | ||||||||
| FaxNumber: | 4059512858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2011 | ||||||||
| LastUpdateDate: | 04/05/2017 | ||||||||
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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 | 106H00000X | 7088A | NC | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 1169 | OK | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.