Provider Demographics
NPI:1215745021
Name:WILSON, ALYCEA LEE
Entity type:Individual
Prefix:
First Name:ALYCEA
Middle Name:LEE
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 1:1331 S BIRD ST APT 103
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1489
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1087 E PARK BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BOSIE
Practice Address - State:ID
Practice Address - Zip Code:83712
Practice Address - Country:US
Practice Address - Phone:208-369-9168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-26
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID23-306234106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician