Provider Demographics
NPI:1699967299
Name:WILSON, REBECCA KATHLEEN (MSW)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:KATHLEEN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17688
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80402-6028
Mailing Address - Country:US
Mailing Address - Phone:720-940-8531
Mailing Address - Fax:720-542-9245
Practice Address - Street 1:6000 E EVANS AVE
Practice Address - Street 2:BUILDING 3 SUITE 100
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-5406
Practice Address - Country:US
Practice Address - Phone:720-514-3425
Practice Address - Fax:303-557-6240
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO91720575Medicaid
COCOA104102Medicare PIN