=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710325766
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILSON'S GARDEN OF HOPE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2013
-----------------------------------------------------
Last Update Date | 06/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3062 DAMASCUS RD SUITE 100
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30909-4068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 762-233-4642
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3478 ESSEX PL
-----------------------------------------------------
City | HEPHZIBAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30815-7172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 762-233-4642
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MS. SHATISHA MATRICE WILSON
-----------------------------------------------------
Credential | M.S.
-----------------------------------------------------
Telephone | 762-233-4642
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LAPC002949
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC006436
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------