Provider Demographics
NPI:1760663694
Name:WILSON, ELIZABETH EDWARDS
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:EDWARDS
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 1:925 HICKORY NUT STREET
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-6925
Mailing Address - Country:US
Mailing Address - Phone:704-390-3735
Mailing Address - Fax:866-828-5520
Practice Address - Street 1:1720 HAMPSHIRE DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28146-7211
Practice Address - Country:US
Practice Address - Phone:704-309-3735
Practice Address - Fax:866-828-2550
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)