Provider Demographics
NPI:1609396233
Name:WILSON, FREDRICK
Entity Type:Individual
Prefix:
First Name:FREDRICK
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5
Mailing Address - Street 2:
Mailing Address - City:RODESSA
Mailing Address - State:LA
Mailing Address - Zip Code:71069-0005
Mailing Address - Country:US
Mailing Address - Phone:318-223-4665
Mailing Address - Fax:
Practice Address - Street 1:4601 N MARKET ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-2971
Practice Address - Country:US
Practice Address - Phone:318-424-8735
Practice Address - Fax:318-424-8739
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health