Provider Demographics
NPI:1437722352
Name:WILSON, GINA SUE (PHD)
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:SUE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 GOLDEN RIDGE RD # F104
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-8871
Mailing Address - Country:US
Mailing Address - Phone:720-469-8140
Mailing Address - Fax:
Practice Address - Street 1:550 GOLDEN RIDGE RD # F104
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80401-8871
Practice Address - Country:US
Practice Address - Phone:720-469-8140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0017364101YM0800X
CO101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health