Provider Demographics
NPI:1821176702
Name:WILSON'S CONSTANT CARE, LLC
Entity Type:Organization
Organization Name:WILSON'S CONSTANT CARE, LLC
Other - Org Name:WILSON'S CONSTANT CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO/EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:NABRENA
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-391-3476
Mailing Address - Street 1:1228 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-1625
Mailing Address - Country:US
Mailing Address - Phone:336-703-9650
Mailing Address - Fax:336-703-9793
Practice Address - Street 1:1228 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-1625
Practice Address - Country:US
Practice Address - Phone:336-703-9650
Practice Address - Fax:336-703-9793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 251S00000X, 385H00000X, 385HR2055X, 385HR2060X
NCMHL-034-201322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite Care
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6604063Medicaid