Provider Demographics
NPI:1306414859
Name:WILSON, MONIQUE YVETTE (LMSW)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:YVETTE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 N EXPRESSWAY STE 301
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-9014
Mailing Address - Country:US
Mailing Address - Phone:770-358-5252
Mailing Address - Fax:
Practice Address - Street 1:139 HENRY PKWY
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-6636
Practice Address - Country:US
Practice Address - Phone:770-358-5252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002017104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA58-2098758Medicaid