Provider Demographics
NPI:1699889634
Name:WILSON, EMILY ENGELLAND (MA)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ENGELLAND
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 9TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3408
Mailing Address - Country:US
Mailing Address - Phone:304-697-5804
Mailing Address - Fax:304-302-0215
Practice Address - Street 1:105 RIVER RD
Practice Address - Street 2:
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504-1205
Practice Address - Country:US
Practice Address - Phone:304-302-2467
Practice Address - Fax:304-302-0215
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV752103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0071720549OtherBLUE CROSS/BLUE SHIELD
WV9480068000Medicaid