Provider Demographics
NPI:1114388568
Name:WILSON, DEMECKA
Entity Type:Individual
Prefix:MRS
First Name:DEMECKA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1644 B CARTER STREET SUITE 2
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373
Mailing Address - Country:US
Mailing Address - Phone:318-414-3065
Mailing Address - Fax:318-414-3067
Practice Address - Street 1:1138 PUFFER RD
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MS
Practice Address - Zip Code:39069-5133
Practice Address - Country:US
Practice Address - Phone:601-472-2310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-14
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health