Provider Demographics
NPI:1174010292
Name:WILSON, CHARLA ANN
Entity Type:Individual
Prefix:
First Name:CHARLA
Middle Name:ANN
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 1:14605 RIVER PLANTATION CT
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-7617
Mailing Address - Country:US
Mailing Address - Phone:228-229-7147
Mailing Address - Fax:228-392-5812
Practice Address - Street 1:2352 E PASS RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3805
Practice Address - Country:US
Practice Address - Phone:228-284-2337
Practice Address - Fax:228-284-2337
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2269101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty