Provider Demographics
NPI:1669655163
Name:WILSON, AIMEE M (PHD)
Entity Type:Individual
Prefix:
First Name:AIMEE
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:AIMEE
Other - Middle Name:M
Other - Last Name:TISDALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:704 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-3805
Mailing Address - Country:US
Mailing Address - Phone:228-806-9936
Mailing Address - Fax:
Practice Address - Street 1:4061 SUZANNE DR
Practice Address - Street 2:SUITE C & C
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-3735
Practice Address - Country:US
Practice Address - Phone:228-396-4434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-07
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS48833103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool