Provider Demographics
NPI:1790814044
Name:WILSON, GAIL CANNON (PHD)
Entity Type:Individual
Prefix:MISS
First Name:GAIL
Middle Name:CANNON
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1419 AMELIA ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-3624
Mailing Address - Country:US
Mailing Address - Phone:504-894-9980
Mailing Address - Fax:504-894-9981
Practice Address - Street 1:1419 AMELIA ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-3624
Practice Address - Country:US
Practice Address - Phone:504-894-9980
Practice Address - Fax:504-894-9981
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA383103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist