Provider Demographics
NPI:1235163064
Name:WILSON, HAROLD O (MA, REHAB COUNSELING)
Entity Type:Individual
Prefix:
First Name:HAROLD
Middle Name:O
Last Name:WILSON
Suffix:
Gender:M
Credentials:MA, REHAB COUNSELING
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2319 SAINT MATTHEWS RD
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-2042
Mailing Address - Country:US
Mailing Address - Phone:803-536-1571
Mailing Address - Fax:803-536-1463
Practice Address - Street 1:1375 GILWAY EXTENSION
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:SC
Practice Address - Zip Code:29059
Practice Address - Country:US
Practice Address - Phone:803-496-3410
Practice Address - Fax:803-496-9185
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC413093Medicaid
SC413093Medicaid