Provider Demographics
NPI:1073156063
Name:WILSON, EBONY N (MSW, LCSWA)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:N
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10014 RED BLUFF CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-8381
Mailing Address - Country:US
Mailing Address - Phone:704-890-5562
Mailing Address - Fax:
Practice Address - Street 1:183 IREDELL AVE
Practice Address - Street 2:
Practice Address - City:TROUTMAN
Practice Address - State:NC
Practice Address - Zip Code:28166
Practice Address - Country:US
Practice Address - Phone:704-872-4045
Practice Address - Fax:704-873-3315
Is Sole Proprietor?:No
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP013694104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker