Provider Demographics
NPI:1639991953
Name:WILSON, ANNIE GRACE (MS, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:GRACE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1181 MOUNT HOLSTON RD
Mailing Address - Street 2:
Mailing Address - City:BLUFF CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37618-4208
Mailing Address - Country:US
Mailing Address - Phone:423-552-4988
Mailing Address - Fax:
Practice Address - Street 1:525 W OAKLAND AVE STE 205
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-1673
Practice Address - Country:US
Practice Address - Phone:423-282-1700
Practice Address - Fax:423-282-9319
Is Sole Proprietor?:No
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1634103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst