Basic Information
| Provider Information | |||||||||
| NPI: | 1659828408 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | ROXANNE | ||||||||
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| Credential: | CAP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 190 | ||||||||
| Address2: | |||||||||
| City: | ST STEPHENS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825240190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078560470 | ||||||||
| FaxNumber: | 3078574383 | ||||||||
| Practice Location | |||||||||
| Address1: | 24 GREAT PLAINS RD | ||||||||
| Address2: | |||||||||
| City: | ARAPAHOE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073526677 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2016 | ||||||||
| LastUpdateDate: | 02/20/2018 | ||||||||
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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 | 101YA0400X | CAP-082 | WY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.