Healthcare Provider Details

I. General information

NPI: 1215339015
Provider Name (Legal Business Name): DANICE WILSON PRACTITIONER, MED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DANICE WILSON-BATES CLINICIAN, MAED

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3961 FLOYD RD SUITE 300158
AUSTELL GA
30106-8535
US

IV. Provider business mailing address

9814 SPINNAKER ST
CHELTENHAM MD
20623-1350
US

V. Phone/Fax

Practice location:
  • Phone: 678-785-7284
  • Fax: 770-438-7929
Mailing address:
  • Phone: 833-551-7284
  • Fax: 240-681-3877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMD
# 7
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: