Provider Demographics
NPI:1609279967
Name:WILSON, SANDRA
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:
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 1:101 RIVER BIRCH DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30116-1860
Mailing Address - Country:US
Mailing Address - Phone:470-955-3190
Mailing Address - Fax:
Practice Address - Street 1:121 JACKSON ST
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-1572
Practice Address - Country:US
Practice Address - Phone:770-251-5873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003843103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool