Provider Demographics
NPI:1427404383
Name:WILSON, CHANDRA (MHS)
Entity Type:Individual
Prefix:
First Name:CHANDRA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 LINE AVE
Mailing Address - Street 2:SUITE 315
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4621
Mailing Address - Country:US
Mailing Address - Phone:318-221-2828
Mailing Address - Fax:318-221-2998
Practice Address - Street 1:1513 LINE AVE
Practice Address - Street 2:SUITE 315
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4621
Practice Address - Country:US
Practice Address - Phone:318-221-2828
Practice Address - Fax:318-221-2998
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health