MEDICARE: ANGELICA NICOLE WILSON LPC

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	101YP2500X	Professional Counselor	068.0136873	VT
2	101YM0800X	Mental Health Counselor	LPC009942	GA
3	101YP2500X	Professional Counselor	11278	SC
4	101YP2500X	Professional Counselor	0701014644	VA
5	101YP2500X	Professional Counselor	137077	IA
6	101YP2500X	Professional Counselor	6401225641	MI
7	101YM0800X	Mental Health Counselor	TPMC1945	FL

General Provider Information

NPI Number	:	1275098733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELICA NICOLE WILSON LPC

Provider Business Mailing Address
First Line	:	228 PEBBLE CREEK DR
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-7420
Country	:	US
Telephone Number	:	404-247-6072
Fax Number	:

Provider Business Practice Location Address
First Line	:	228 PEBBLE CREEK DR
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-7420
Country	:	US
Telephone Number	:	404-247-6072
Fax Number	:

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

Provider Enumeration Date	:	02/08/2019
Last Update Date	:	04/06/2026

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