Provider Demographics
NPI:1326517855
Name:PICKENS-WILSON, MARY FRANCES
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:FRANCES
Last Name:PICKENS-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 1:4628 QUINTON LANE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269
Mailing Address - Country:US
Mailing Address - Phone:678-438-6534
Mailing Address - Fax:
Practice Address - Street 1:4628 QUINTON LANE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269
Practice Address - Country:US
Practice Address - Phone:678-438-6534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician