Provider Demographics
NPI:1124574959
Name:WILSON, PATTY
Entity Type:Individual
Prefix:
First Name:PATTY
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 1:2555 E WOOD ST
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TN
Mailing Address - Zip Code:38242-7990
Mailing Address - Country:US
Mailing Address - Phone:731-641-4546
Mailing Address - Fax:731-641-4546
Practice Address - Street 1:2555 E. WOOD STREET
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TN
Practice Address - Zip Code:38242
Practice Address - Country:US
Practice Address - Phone:731-641-4545
Practice Address - Fax:731-641-4546
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)