Provider Demographics
NPI:1578057857
Name:WILSON, SELENA MICHELLE
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:MICHELLE
Last Name: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 1:131 COUNTRY LN APT B
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-3912
Mailing Address - Country:US
Mailing Address - Phone:931-478-5518
Mailing Address - Fax:
Practice Address - Street 1:1820 MEMORIAL CIR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-4539
Practice Address - Country:US
Practice Address - Phone:931-920-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker