Provider Demographics
NPI:1003471632
Name:WILSON, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-0308
Mailing Address - Country:US
Mailing Address - Phone:770-880-2185
Mailing Address - Fax:
Practice Address - Street 1:11578 HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:GA
Practice Address - Zip Code:30747-5873
Practice Address - Country:US
Practice Address - Phone:706-857-5441
Practice Address - Fax:706-857-7607
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003040101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional