Healthcare Provider Details

I. General information

NPI: 1265152243
Provider Name (Legal Business Name): TABITHA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2022
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

848 HIRAM ACWORTH HWY STE 100
HIRAM GA
30141-2399
US

IV. Provider business mailing address

111 RIDGEVIEW CT
PEACHTREE CITY GA
30269-1533
US

V. Phone/Fax

Practice location:
  • Phone: 678-664-4311
  • Fax:
Mailing address:
  • Phone: 678-895-7368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC017084
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: