Healthcare Provider Details

I. General information

NPI: 1194839795
Provider Name (Legal Business Name): KEVIN S WILSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 RIVERSIDE PKWY ATL VA CBOC
LAWRENCEVILLE GA
30043-5937
US

IV. Provider business mailing address

2691 HOLLY SPRINGS DR
SNELLVILLE GA
30078-5957
US

V. Phone/Fax

Practice location:
  • Phone: 404-417-1726
  • Fax: 404-417-1708
Mailing address:
  • Phone: 770-978-7124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW002478
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: