Provider Demographics
NPI:1649674441
Name:WILSON THOMPSON, ANDRIA EDRIES
Entity type:Individual
Prefix:
First Name:ANDRIA
Middle Name:EDRIES
Last Name:WILSON THOMPSON
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 1:1810 BASHAW ST NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-9446
Mailing Address - Country:US
Mailing Address - Phone:516-610-6884
Mailing Address - Fax:
Practice Address - Street 1:1810 BASHAW ST NW
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-9446
Practice Address - Country:US
Practice Address - Phone:516-610-6884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-22
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator