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NPI Code Detail

MEDICARE: MR. TERRY DWAYNE WILSON ASSOCIATE

MEDICARE: MR. TERRY DWAYNE WILSON ASSOCIATE
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
1101YA0400XAddiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number : 1124246475
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. TERRY DWAYNE WILSON ASSOCIATE
Provider Business Mailing Address
First Line : 978 BASSMAN LN APT 304
Second Line :
City : FAYETTEVILLE
State : NC
Zip : 28314-2189
Country : US
Telephone Number : 910-723-1898
Fax Number :
Provider Business Practice Location Address
First Line : 3423 MELROSE RD # A
Second Line :
City : FAYETTEVILLE
State : NC
Zip : 28304-1608
Country : US
Telephone Number : 910-864-8739
Fax Number : 910-864-8222
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/23/2007
Last Update Date : 07/08/2007

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