Provider Demographics
NPI:1043543143
Name:WILSON, VANDE
Entity Type:Individual
Prefix:
First Name:VANDE
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 1734
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28329-1734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:312 COLLEGE ST
Practice Address - Street 2:SUITE C
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-4181
Practice Address - Country:US
Practice Address - Phone:910-299-0848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-08
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7604101YP2500X
101Y00000X, 101YM0800X
NC2064101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)