Healthcare Provider Details

I. General information

NPI: 1629562673
Provider Name (Legal Business Name): ADRIANNA CELESTE WILSON LCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6614 WILLOWBROOK LN
CONCORD NC
28027-5358
US

IV. Provider business mailing address

6614 WILLOWBROOK LN
CONCORD NC
28027-5358
US

V. Phone/Fax

Practice location:
  • Phone: 704-967-9418
  • Fax: 833-542-3336
Mailing address:
  • Phone: 704-967-9418
  • Fax: 833-542-3336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number22769
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-23182
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: