Basic Information
| Provider Information | |||||||||
| NPI: | 1730647033 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | EVIE | ||||||||
| MiddleName: | NOELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BCBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MERRITT | ||||||||
| OtherFirstName: | EVIE | ||||||||
| OtherMiddleName: | NOELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10730 E BETHANY DR | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800142644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7206349431 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 390 UNION BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802286514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039898169 | ||||||||
| FaxNumber: | 3039844366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2019 | ||||||||
| LastUpdateDate: | 02/05/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 103K00000X | 1-22-57807 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.