Provider Demographics
NPI:1790840981
Name:WILSON, LINDA ALICE (PHD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:ALICE
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 1:2325 BROOKSTONE CENTRE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904
Mailing Address - Country:US
Mailing Address - Phone:706-653-6841
Mailing Address - Fax:
Practice Address - Street 1:2325 BROOKSTONE CENTRE PARKWAY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904
Practice Address - Country:US
Practice Address - Phone:706-653-6841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1288103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R12888Medicare UPIN
68BBFPTMedicare ID - Type Unspecified