Healthcare Provider Details

I. General information

NPI: 1144671991
Provider Name (Legal Business Name): MCKENZIE LAINE WILSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4030 WINBURN LN
WINSTON SALEM NC
27106-2938
US

IV. Provider business mailing address

4030 WINBURN LN
WINSTON SALEM NC
27106-2938
US

V. Phone/Fax

Practice location:
  • Phone: 336-529-2557
  • Fax:
Mailing address:
  • Phone: 336-529-2557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC011603
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: