Provider Demographics
NPI:1083939144
Name:WILSON, DEIRDRE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:DEIRDRE
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 1:5834 AMITY SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-2604
Mailing Address - Country:US
Mailing Address - Phone:704-804-3771
Mailing Address - Fax:
Practice Address - Street 1:5834 AMITY SPRINGS DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-2604
Practice Address - Country:US
Practice Address - Phone:704-804-3771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-01
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NCC0077621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health