Provider Demographics
NPI:1700120409
Name:WILSON, DEMETRICE (LCAS-A)
Entity Type:Individual
Prefix:
First Name:DEMETRICE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:NC
Mailing Address - Zip Code:27892-2472
Mailing Address - Country:US
Mailing Address - Phone:252-792-7812
Mailing Address - Fax:252-792-7812
Practice Address - Street 1:132 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:NC
Practice Address - Zip Code:27892-2472
Practice Address - Country:US
Practice Address - Phone:252-792-7812
Practice Address - Fax:252-792-7812
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2888-A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health