Provider Demographics
NPI:1891147245
Name:WILSON, NICKIE DEANN (LADC/MH)
Entity type:Individual
Prefix:
First Name:NICKIE
Middle Name:DEANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LADC/MH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-1088
Mailing Address - Country:US
Mailing Address - Phone:918-342-0770
Mailing Address - Fax:918-342-0087
Practice Address - Street 1:3100 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-1088
Practice Address - Country:US
Practice Address - Phone:918-342-0770
Practice Address - Fax:918-342-0087
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OK1345101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator