MEDICARE: CHARLA ANN WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	2269	MS

General Provider Information

NPI Number	:	1174010292
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLA ANN WILSON

Provider Business Mailing Address
First Line	:	14605 RIVER PLANTATION CT
Second Line	:
City	:	BILOXI
State	:	MS
Zip	:	39532-7617
Country	:	US
Telephone Number	:	228-229-7147
Fax Number	:	228-392-5812

Provider Business Practice Location Address
First Line	:	2352 E PASS RD
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39507-3805
Country	:	US
Telephone Number	:	228-284-2337
Fax Number	:	228-284-2337

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2018
Last Update Date	:	04/13/2018

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Directions to “ CHARLA ANN WILSON ” Practice Location

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