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General NPI Number Information
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NPI Number | 1306656285
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Entity Type | Individual
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Provider Name | ANGELA BYRD WILSON CCAC II
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Gender | Female
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Dates
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Enumeration Date | 01/13/2025
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Last Update Date | 01/13/2025
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Provider Practice Location Address
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Address Line | 5680 FULTON INDUSTRIAL BLVD SW
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City | ATLANTA
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State | GA
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Zip | 30336-2659
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Country | US
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Telephone | 404-484-9640
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Fax |
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Provider Business Mailing Address
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Address Line | 7263 BLUESTONE DR
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City | RIVERDALE
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State | GA
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Zip | 30296-1513
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Country | US
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Telephone | 404-484-9640
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Fax |
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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 | 172V00000X
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Taxonomy Name | Community Health Worker
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 87881
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License Number State | GA
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