Provider Demographics
NPI:1548378631
Name:WILSON, TRINA RENEE' (PHD, MDIV, LCSW)
Entity Type:Individual
Prefix:DR
First Name:TRINA
Middle Name:RENEE'
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD, MDIV, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5955 TIBOR DR NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-6949
Mailing Address - Country:US
Mailing Address - Phone:404-931-6535
Mailing Address - Fax:770-420-8101
Practice Address - Street 1:617 ROSWELL ST NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-3502
Practice Address - Country:US
Practice Address - Phone:404-931-6535
Practice Address - Fax:770-420-8101
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1764101Y00000X, 101YA0400X, 101YM0800X, 101YP1600X, 101YP2500X, 101YS0200X, 104100000X, 1041C0700X, 1041S0200X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist