Provider Demographics
NPI:1306959077
Name:WILSON, NATHAN RAY (CMA)
Entity type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:RAY
Last Name:WILSON
Suffix:
Gender:M
Credentials:CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4825 BISMARC DR
Mailing Address - Street 2:
Mailing Address - City:DEL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115-4413
Mailing Address - Country:US
Mailing Address - Phone:405-208-8753
Mailing Address - Fax:
Practice Address - Street 1:804 W CHOCTAW AVE
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-2310
Practice Address - Country:US
Practice Address - Phone:405-222-0622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health