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General NPI Number Information
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NPI Number | 1356548549
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Entity Type | Organization
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Legal Business Name | SHIRLEY A WILSON
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Dates
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Enumeration Date | 06/29/2007
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Last Update Date | 06/30/2008
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Provider Practice Location Address
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Address Line | 7160 TCHULAHOMA RD # B STE 1
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City | SOUTHAVEN
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State | MS
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Zip | 38671-9266
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Country | US
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Telephone | 662-349-6658
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Fax | 662-349-6856
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Provider Business Mailing Address
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Address Line | 7160 TCHULAHOMA RD # B STE 1
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City | SOUTHAVEN
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State | MS
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Zip | 38671-9266
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Country | US
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Telephone | 662-349-6658
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Fax | 662-349-6856
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Authorized Official
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Title or Position | PSYCHOLOGIST OWNER
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Name | DR. SHIRLEY ANN WILSON
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Credential | PHD
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Telephone | 662-349-6658
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TB0200X
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Taxonomy Name | Cognitive & Behavioral Psychologist
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License Number |
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number |
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License Number State | MS
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Taxonomy #3
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State | MS
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