Provider Demographics
NPI:1356548549
Name:SHIRLEY A WILSON
Entity type:Organization
Organization Name:SHIRLEY A WILSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:662-349-6658
Mailing Address - Street 1:7160 TCHULAHOMA RD # B
Mailing Address - Street 2:STE 1
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9266
Mailing Address - Country:US
Mailing Address - Phone:662-349-6658
Mailing Address - Fax:662-349-6856
Practice Address - Street 1:7160 TCHULAHOMA RD # B
Practice Address - Street 2:STE 1
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9266
Practice Address - Country:US
Practice Address - Phone:662-349-6658
Practice Address - Fax:662-349-6856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS103TB0200X, 103TC2200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty