Healthcare Provider Details

I. General information

NPI: 1285359067
Provider Name (Legal Business Name): ANDREA LATISHA HOUSTON-WILSON LCSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2022
Last Update Date: 06/30/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 US HIGHWAY 421 SOUTH
LILLINGTON NC
27506
US

IV. Provider business mailing address

284 EXECUTIVE PARK DR STE 100
CONCORD NC
28025-1833
US

V. Phone/Fax

Practice location:
  • Phone: 910-893-5727
  • Fax: 910-893-6404
Mailing address:
  • Phone: 704-939-1101
  • Fax: 704-939-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP014496
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: