Provider Demographics
NPI:1164847364
Name:WILKERSON, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:WILKERSON
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:PO BOX 3788
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29230-3788
Mailing Address - Country:US
Mailing Address - Phone:803-733-5969
Mailing Address - Fax:803-217-0026
Practice Address - Street 1:1332 PICKENS ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3430
Practice Address - Country:US
Practice Address - Phone:803-771-4160
Practice Address - Fax:803-771-4367
Is Sole Proprietor?:No
Enumeration Date:2014-02-25
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC106091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCLW1022Medicaid