Provider Demographics
NPI:1598442519
Name:WILSON, TANITH JO (CADC)
Entity Type:Individual
Prefix:MRS
First Name:TANITH
Middle Name:JO
Last Name:WILSON
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:365 WALLER AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2924
Mailing Address - Country:US
Mailing Address - Phone:859-319-2610
Mailing Address - Fax:859-209-2964
Practice Address - Street 1:365 WALLER AVE STE 230
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2924
Practice Address - Country:US
Practice Address - Phone:859-319-2610
Practice Address - Fax:859-209-2964
Is Sole Proprietor?:No
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY267258101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)