Provider Demographics
NPI:1245519321
Name:WILSON-FANT, DONNA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:
Last Name:WILSON-FANT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 BRIDGE GRV
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-5455
Mailing Address - Country:US
Mailing Address - Phone:770-709-1546
Mailing Address - Fax:
Practice Address - Street 1:341 PONCE DE LEON AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2012
Practice Address - Country:US
Practice Address - Phone:404-616-6614
Practice Address - Fax:404-616-9790
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW004421104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker