Healthcare Provider Details

I. General information

NPI: 1982704482
Provider Name (Legal Business Name): CARLA JO WILEMON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2434 S EASON BLVD
TUPELO MS
38804-6942
US

IV. Provider business mailing address

PO BOX 764
FULTON MS
38843-0764
US

V. Phone/Fax

Practice location:
  • Phone: 662-844-1717
  • Fax: 662-680-6416
Mailing address:
  • Phone: 662-862-3453
  • Fax:

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 Code104100000X
TaxonomySocial Worker
License NumberM7451
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: