=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780862615
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDI WILSON LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2008
-----------------------------------------------------
Last Update Date | 12/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 HARTSFIELD CENTER PKWY STE 500
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30354-1377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-594-4824
-----------------------------------------------------
Fax | 470-777-2229
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 245 N HIGHLAND AVE NE STE 230-374
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30307-1936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-594-4824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CSW006629
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------