=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104223999
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. KEN WILSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2014
-----------------------------------------------------
Last Update Date | 11/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2610 COMMONS BLVD
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30909-2080
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-733-1935
-----------------------------------------------------
Fax | 706-667-8727
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2610 COMMONS BLVD
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30909-2080
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-733-1935
-----------------------------------------------------
Fax | 706-667-8727
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 564
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------