Provider Demographics
NPI:1093051351
Name:WILSON, ANGELA K (LPC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:K
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC
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 637
Mailing Address - Street 2:300 BROADWAY AVENUE
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-0011
Mailing Address - Country:US
Mailing Address - Phone:706-447-9050
Mailing Address - Fax:
Practice Address - Street 1:300 BROADWAY AVE
Practice Address - Street 2:POST OFFICE BOX 637
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517
Practice Address - Country:US
Practice Address - Phone:706-447-9050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-13
Last Update Date:2015-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005354101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional