Healthcare Provider Details

I. General information

NPI: 1114388568
Provider Name (Legal Business Name): MRS. DEMECKA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2016
Last Update Date: 07/30/2021
Certification Date: 07/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1138 PUFFER RD
FAYETTE MS
39069-5133
US

IV. Provider business mailing address

1644 B CARTER STREET SUITE 2
VIDALIA LA
71373
US

V. Phone/Fax

Practice location:
  • Phone: 601-472-2310
  • Fax:
Mailing address:
  • Phone: 318-414-3065
  • Fax: 318-414-3067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: