1275768285 NPI number — HEIDI WILSON MBA, MA, LPC, CACII

Table of content: HEIDI WILSON MBA, MA, LPC, CACII (NPI 1275768285)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275768285 NPI number — HEIDI WILSON MBA, MA, LPC, CACII

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
HEIDI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MBA, MA, LPC, CACII
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275768285
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1630 30TH ST STE A
Provider Second Line Business Mailing Address:
PMB 217
Provider Business Mailing Address City Name:
BOULDER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80301-1045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-530-8227
Provider Business Mailing Address Fax Number:
303-927-6016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1137 PEARL ST
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
BOULDER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80302-5159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-530-8227
Provider Business Practice Location Address Fax Number:
303-927-6016
Provider Enumeration Date:
05/19/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  6191 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 4075 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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