=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215238761
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. DEBORAH J WILSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2010
-----------------------------------------------------
Last Update Date | 11/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2818 STEPHENS HWY
-----------------------------------------------------
City | MOUNT HOLLY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71758-6095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-554-3122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2818 STEPHENS HWY
-----------------------------------------------------
City | MOUNT HOLLY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71758-6095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-554-3122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | LPE 93-04I
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------