Provider Demographics
NPI:1205011327
Name:WILSON, GEORGE MARC (LCSW)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:MARC
Last Name:WILSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WALNUT RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72476-1431
Mailing Address - Country:US
Mailing Address - Phone:870-886-5303
Mailing Address - Fax:870-886-7002
Practice Address - Street 1:1815 PLEASANT GROVE RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401
Practice Address - Country:US
Practice Address - Phone:870-933-6886
Practice Address - Fax:870-933-9395
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2210-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5A755OtherBCBS
AR174440795Medicaid
AR174440795Medicaid
AR5A755C455Medicare PIN