Provider Demographics
NPI:1104319987
Name:WILSON, NATALIE
Entity type:Individual
Prefix:
First Name:NATALIE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12222 S 1000 E STE 3
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-3203
Mailing Address - Country:US
Mailing Address - Phone:801-987-3592
Mailing Address - Fax:801-658-0604
Practice Address - Street 1:6013 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-5220
Practice Address - Country:US
Practice Address - Phone:801-255-5131
Practice Address - Fax:801-658-0604
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty