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General NPI Number Information
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NPI Number | 1215339015
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Entity Type | Individual
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Provider Name | DANICE WILSON PRACTITIONER, MED
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Gender | Female
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Dates
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Enumeration Date | 09/23/2014
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Last Update Date | 09/23/2014
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Provider Practice Location Address
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Address Line | 3961 FLOYD RD SUITE 300158
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City | AUSTELL
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State | GA
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Zip | 30106-8535
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Country | US
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Telephone | 678-785-7284
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Fax | 770-438-7929
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Provider Business Mailing Address
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Address Line | 3961 FLOYD RD SUITE 300158
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City | AUSTELL
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State | GA
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Zip | 30106-8535
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Country | US
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Telephone | 678-785-7284
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Fax | 770-438-7929
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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 | 101YP1600X
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Taxonomy Name | Pastoral Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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