Provider Demographics
NPI:1083850739
Name:WILSON, EDWINA (LCSW)
Entity Type:Individual
Prefix:
First Name:EDWINA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 RIDGEVIEW CT
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72227-2340
Mailing Address - Country:US
Mailing Address - Phone:501-352-6101
Mailing Address - Fax:
Practice Address - Street 1:4 SHACKLEFORD PLZ
Practice Address - Street 2:SUITE 210
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-1826
Practice Address - Country:US
Practice Address - Phone:501-352-6101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-31
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1076-C101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health