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NPI Code Detail

MEDICARE: STEPHANIE WILSON

MEDICARE: STEPHANIE WILSON
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) Counselor1423LA

General Provider Information

NPI Number : 1700312576
Entity Type Code : Individual
Provider Name (Legal Business Name) : STEPHANIE WILSON
Provider Business Mailing Address
First Line : 5925 GREENWELL SPRINGS RD
Second Line :
City : BATON ROUGE
State : LA
Zip : 70806-1620
Country : US
Telephone Number : 225-926-7911
Fax Number : 225-926-7914
Provider Business Practice Location Address
First Line : 5925 GREENWELL SPRINGS RD
Second Line :
City : BATON ROUGE
State : LA
Zip : 70806-1620
Country : US
Telephone Number : 225-926-7911
Fax Number : 225-926-7914
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/11/2017
Last Update Date : 05/11/2017

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