Provider Demographics
NPI:1427820620
Name:WILSON, EMILY JANE
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:JANE
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 1:703 MARIPOSA CIR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-1606
Mailing Address - Country:US
Mailing Address - Phone:512-923-0018
Mailing Address - Fax:
Practice Address - Street 1:4861 WILLIAMS DR STE 101
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78633-2425
Practice Address - Country:US
Practice Address - Phone:737-295-4536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician