MEDICARE: DR. CARMEN NICOLE WILSON-REESE PSY.D.

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	103TC0700X	Clinical Psychologist	PSY002035	GA

General Provider Information

NPI Number	:	1538487087
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARMEN NICOLE WILSON-REESE PSY.D.

Provider Business Mailing Address
First Line	:	299 JULE INGRAM RD NE
Second Line	:
City	:	MILLEDGEVILLE
State	:	GA
Zip	:	31061-7962
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	34 PEACHTREE ST NW
Second Line	:	SUITE 770
City	:	ATLANTA
State	:	GA
Zip	:	30303-2316
Country	:	US
Telephone Number	:	478-445-5501
Fax Number	:

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

Provider Enumeration Date	:	05/08/2010
Last Update Date	:	05/08/2010

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