Healthcare Provider Details

I. General information

NPI: 1356548549
Provider Name (Legal Business Name): SHIRLEY A WILSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7160 TCHULAHOMA RD # B STE 1
SOUTHAVEN MS
38671-9266
US

IV. Provider business mailing address

7160 TCHULAHOMA RD # B STE 1
SOUTHAVEN MS
38671-9266
US

V. Phone/Fax

Practice location:
  • Phone: 662-349-6658
  • Fax: 662-349-6856
Mailing address:
  • Phone: 662-349-6658
  • Fax: 662-349-6856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateMS

VIII. Authorized Official

Name: DR. SHIRLEY ANN WILSON
Title or Position: PSYCHOLOGIST OWNER
Credential: PHD
Phone: 662-349-6658