Healthcare Provider Details

I. General information

NPI: 1609114891
Provider Name (Legal Business Name): MRS. SARA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2013
Last Update Date: 09/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 CHUCK GRAY CT
OWENSBORO KY
42303
US

IV. Provider business mailing address

1321 MURFREESBORO PIKE STE 702
NASHVILLE TN
37217-2679
US

V. Phone/Fax

Practice location:
  • Phone: 270-702-4641
  • Fax: 615-577-5654
Mailing address:
  • Phone: 844-359-7629
  • Fax: 615-577-5654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-75804
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: