Provider Demographics
NPI:1255709564
Name:WILSON, TIA LYNN
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 E WASHINGTON AVE
Mailing Address - Street 2:UNIT LL
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-4481
Mailing Address - Country:US
Mailing Address - Phone:314-503-7464
Mailing Address - Fax:
Practice Address - Street 1:121 E WASHINGTON AVE
Practice Address - Street 2:UNIT LL
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-4481
Practice Address - Country:US
Practice Address - Phone:314-503-7464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130299801041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool