Provider Demographics
NPI:1033256938
Name:WILSON, TRACY C (MED)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:C
Last Name:WILSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 BRADLEY ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3217
Mailing Address - Country:US
Mailing Address - Phone:770-832-9140
Mailing Address - Fax:770-832-3046
Practice Address - Street 1:215 BRADLEY ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3217
Practice Address - Country:US
Practice Address - Phone:770-832-9140
Practice Address - Fax:770-832-3046
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2748101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA844101180AMedicaid
GA11643300OtherCAQH