Provider Demographics
NPI:1710325766
Name:WILSON'S GARDEN OF HOPE
Entity Type:Organization
Organization Name:WILSON'S GARDEN OF HOPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHATISHA
Authorized Official - Middle Name:MATRICE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:762-233-4642
Mailing Address - Street 1:3478 ESSEX PL
Mailing Address - Street 2:
Mailing Address - City:HEPHZIBAH
Mailing Address - State:GA
Mailing Address - Zip Code:30815-7172
Mailing Address - Country:US
Mailing Address - Phone:762-233-4642
Mailing Address - Fax:
Practice Address - Street 1:3062 DAMASCUS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-4068
Practice Address - Country:US
Practice Address - Phone:762-233-4642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALAPC002949101YP2500X
GALPC006436101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty