Provider Demographics
NPI:1275710667
Name:WILSON, KENYATTA (MS)
Entity Type:Individual
Prefix:MRS
First Name:KENYATTA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:KENYATTA
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:815 BANKHEAD HWY STE G
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-1970
Mailing Address - Country:US
Mailing Address - Phone:770-820-3070
Mailing Address - Fax:
Practice Address - Street 1:500 OLD BREMEN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-5216
Practice Address - Country:US
Practice Address - Phone:770-820-3070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007401101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional