Provider Demographics
NPI:1962721928
Name:WILSON, RAE (MSW)
Entity type:Individual
Prefix:
First Name:RAE
Middle Name:
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 5111
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73702-5111
Mailing Address - Country:US
Mailing Address - Phone:972-742-2815
Mailing Address - Fax:
Practice Address - Street 1:2929 E RANDOLPH AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-4667
Practice Address - Country:US
Practice Address - Phone:972-742-2815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-28
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker