=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437817525
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LINDA A. WILSON PH.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2021
-----------------------------------------------------
Last Update Date | 12/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 681 LAYFIELD BRANCH RD
-----------------------------------------------------
City | HAMILTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31811-4110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-580-1600
-----------------------------------------------------
Fax | 706-243-1346
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 681 LAYFIELD BRANCH RD
-----------------------------------------------------
City | HAMILTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31811-4110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-580-1600
-----------------------------------------------------
Fax | 706-243-1346
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. LINDA A. WILSON
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 706-580-1600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------