Healthcare Provider Details

I. General information

NPI: 1497618110
Provider Name (Legal Business Name): JULIANA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 SW MAYNARD RD STE 2004472
CARY NC
27511-4472
US

IV. Provider business mailing address

PO BOX 748465
ATLANTA GA
30374-8465
US

V. Phone/Fax

Practice location:
  • Phone: 855-675-4144
  • Fax: 617-807-0958
Mailing address:
  • Phone: 855-284-7483
  • Fax: 617-807-0958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP022060
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: