Healthcare Provider Details

I. General information

NPI: 1013838259
Provider Name (Legal Business Name): BRANDON L WILSON LAPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 COBB PKWY NW # 3604
ACWORTH GA
30101-9532
US

IV. Provider business mailing address

2506 TIMBERLY DR SE
MARIETTA GA
30060-7038
US

V. Phone/Fax

Practice location:
  • Phone: 404-532-9602
  • Fax:
Mailing address:
  • Phone: 770-356-0216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPC010925
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: