Provider Demographics
NPI:1972929636
Name:WILSON, CLARENCE J
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:J
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4209 LAKELAND DR STE 204
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9212
Mailing Address - Country:US
Mailing Address - Phone:919-389-2249
Mailing Address - Fax:
Practice Address - Street 1:4209 LAKELAND DR STE 204
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9212
Practice Address - Country:US
Practice Address - Phone:919-389-2249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-05
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health