Provider Demographics
NPI:1033653720
Name:WILSON, TINA
Entity Type:Individual
Prefix:
First Name:TINA
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 1:205 WHIPPOORWILL LN
Mailing Address - Street 2:
Mailing Address - City:MT HOLLY
Mailing Address - State:NC
Mailing Address - Zip Code:28120-9761
Mailing Address - Country:US
Mailing Address - Phone:704-574-1549
Mailing Address - Fax:
Practice Address - Street 1:139 WHIPPOORWILL LN
Practice Address - Street 2:
Practice Address - City:MT HOLLY
Practice Address - State:NC
Practice Address - Zip Code:28120-9761
Practice Address - Country:US
Practice Address - Phone:704-574-1549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-14
Last Update Date:2017-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-036-323320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental IllnessGroup - Multi-Specialty