Provider Demographics
NPI:1407204456
Name:WILKINS, AVA L
Entity Type:Individual
Prefix:
First Name:AVA
Middle Name:L
Last Name:WILKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AVA
Other - Middle Name:L
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:187 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29306-3234
Mailing Address - Country:US
Mailing Address - Phone:864-582-7588
Mailing Address - Fax:864-582-0431
Practice Address - Street 1:187 W BROAD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29306-3234
Practice Address - Country:US
Practice Address - Phone:864-582-7588
Practice Address - Fax:864-582-0431
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAD10SPMedicaid