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General NPI Number Information
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NPI Number | 1043688716
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Entity Type | Individual
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Provider Name | MR. ANDREW WILSON
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Gender | Male
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Dates
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Enumeration Date | 09/11/2015
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Last Update Date | 09/11/2015
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Provider Practice Location Address
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Address Line | 6007 FINANCIAL PLZ STE 213
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City | SHREVEPORT
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State | LA
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Zip | 71129-2638
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Country | US
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Telephone | 318-458-5158
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Fax | 318-220-8108
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Provider Business Mailing Address
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Address Line | 9817 HADRIANS WAY
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City | SHREVEPORT
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State | LA
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Zip | 71118-4843
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Country | US
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Telephone | 318-458-5158
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Fax | 318-220-8108
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 8660
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License Number State | LA
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