Provider Demographics
NPI:1376634659
Name:WILSON, AMANDA L (MBA, CADC)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:MBA, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1196 PALMETTO ROAD
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804
Mailing Address - Country:US
Mailing Address - Phone:662-566-2551
Mailing Address - Fax:
Practice Address - Street 1:REGION III MENTAL HEALTH CENTER
Practice Address - Street 2:920 BOONE STREET
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804
Practice Address - Country:US
Practice Address - Phone:662-844-3531
Practice Address - Fax:662-844-1757
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS02-0028W101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)