Provider Demographics
NPI:1619605169
Name:WILSON, CYNTHIA PRETRICE
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:PRETRICE
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 1:2261 SEMMES DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-3401
Mailing Address - Country:US
Mailing Address - Phone:334-391-7225
Mailing Address - Fax:
Practice Address - Street 1:608 DIBBLE ST
Practice Address - Street 2:
Practice Address - City:TUSKEGEE
Practice Address - State:AL
Practice Address - Zip Code:36083-1509
Practice Address - Country:US
Practice Address - Phone:334-947-5901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALALCO3355101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty