Healthcare Provider Details

I. General information

NPI: 1548696388
Provider Name (Legal Business Name): TINA ANDREA WILSON LCAS-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2013
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8430 UNIVERSITY EXEC PARK DR STE. 655
CHARLOTTE NC
28262-1350
US

IV. Provider business mailing address

8430 UNIVERSITY EXEC PARK DR STE. 655
CHARLOTTE NC
28262-1350
US

V. Phone/Fax

Practice location:
  • Phone: 704-596-5553
  • Fax: 704-596-1556
Mailing address:
  • Phone: 704-596-5553
  • Fax: 704-596-1556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3496A
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: