MEDICARE: DR. CORLISSA J WILSON ED.D, LPC, NCC, NCSC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	002236	GA

General Provider Information

NPI Number	:	1033732946
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CORLISSA J WILSON ED.D, LPC, NCC, NCSC

Provider Business Mailing Address
First Line	:	3217 WARREN CREEK DR
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-9044
Country	:	US
Telephone Number	:	404-435-3388
Fax Number	:

Provider Business Practice Location Address
First Line	:	3217 WARREN CREEK DR
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-9044
Country	:	US
Telephone Number	:	404-435-3388
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/26/2020
Last Update Date	:	05/26/2020

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