Healthcare Provider Details

I. General information

NPI: 1023304599
Provider Name (Legal Business Name): JOE WILSON L.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 02/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 PIERCE AVENUE
MACON GA
31204
US

IV. Provider business mailing address

144 PIERCE AVENUE
MACON GA
31204
US

V. Phone/Fax

Practice location:
  • Phone: 478-475-4608
  • Fax: 478-476-8397
Mailing address:
  • Phone: 478-475-4608
  • Fax: 478-476-8397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC003234
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: