Healthcare Provider Details

I. General information

NPI: 1003471632
Provider Name (Legal Business Name): MARY WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 05/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11578 HIGHWAY 27
SUMMERVILLE GA
30747-5873
US

IV. Provider business mailing address

PO BOX 308
CARTERSVILLE GA
30120-0308
US

V. Phone/Fax

Practice location:
  • Phone: 706-857-5441
  • Fax: 706-857-7607
Mailing address:
  • Phone: 770-880-2185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number003040
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: