Provider Demographics
NPI:1053638759
Name:WILSON, CHERRELLE L (MHPP)
Entity Type:Individual
Prefix:
First Name:CHERRELLE
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 AUTUMN RD
Mailing Address - Street 2:STE 3
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-3704
Mailing Address - Country:US
Mailing Address - Phone:501-221-1941
Mailing Address - Fax:501-221-1553
Practice Address - Street 1:1014 AUTUMN RD
Practice Address - Street 2:STE 3
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-3704
Practice Address - Country:US
Practice Address - Phone:501-221-1941
Practice Address - Fax:501-221-1553
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-21
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health