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General NPI Number Information
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NPI Number | 1770560401
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Entity Type | Individual
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Provider Name | SUSAN ANNETTE WILSON M.ED
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Gender | Female
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Dates
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Enumeration Date | 12/23/2005
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Last Update Date | 09/15/2014
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Provider Practice Location Address
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Address Line | 3715 BARDSTOWN ROAD, SUITE 415 FAMILY LINKS
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City | LOUISVILLE
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State | KY
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Zip | 40218
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Country | US
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Telephone | 502-639-0152
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Fax |
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Provider Business Mailing Address
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Address Line | 1733 BONNYCASTLE AVE
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City | LOUISVILLE
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State | KY
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Zip | 40205-1014
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Country | US
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Telephone | 502-417-9881
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | KY-1002
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | KY-0488
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License Number State | KY
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