Provider Demographics
NPI:1124210307
Name:WILSON, SARA ELIZABETH (MA,EDS,LPC)
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:ELIZABETH
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA,EDS,LPC
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:
Other - Last Name:FAZLULAHI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA,EDS,LPC
Mailing Address - Street 1:7257 DRURY LN
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:NC
Mailing Address - Zip Code:28037-8520
Mailing Address - Country:US
Mailing Address - Phone:704-975-0362
Mailing Address - Fax:
Practice Address - Street 1:7257 DRURY LN
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:NC
Practice Address - Zip Code:28037-8520
Practice Address - Country:US
Practice Address - Phone:704-975-0362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-13
Last Update Date:2015-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9114101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6104947Medicaid