Provider Demographics
NPI:1013234350
Name:WILSON, ANDRIA (MS, LPC-MHSP, CET1)
Entity Type:Individual
Prefix:
First Name:ANDRIA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, LPC-MHSP, CET1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4646 POPLAR AVE STE 519
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-4435
Mailing Address - Country:US
Mailing Address - Phone:901-401-0198
Mailing Address - Fax:901-231-7594
Practice Address - Street 1:4646 POPLAR AVE STE 519
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4435
Practice Address - Country:US
Practice Address - Phone:901-401-0198
Practice Address - Fax:901-231-7594
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-27
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
373H00000X
TN4456101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist