Provider Demographics
NPI:1134798549
Name:WILSON, CHARLIZE BRIELLE
Entity type:Individual
Prefix:
First Name:CHARLIZE
Middle Name:BRIELLE
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 1:11576 S STATE ST STE 1202A
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-7119
Mailing Address - Country:US
Mailing Address - Phone:385-365-5881
Mailing Address - Fax:
Practice Address - Street 1:11576 S STATE ST STE 1202A
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-7119
Practice Address - Country:US
Practice Address - Phone:385-365-5881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-21
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14239643-60091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical