Provider Demographics
NPI:1700329950
Name:WILMOT, AYNSLEE CAMILLE
Entity Type:Individual
Prefix:
First Name:AYNSLEE
Middle Name:CAMILLE
Last Name:WILMOT
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 1:611 E WASHINGTON ST
Mailing Address - Street 2:APT 703
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3700
Mailing Address - Country:US
Mailing Address - Phone:318-840-4530
Mailing Address - Fax:
Practice Address - Street 1:2924 KNIGHT ST
Practice Address - Street 2:SUITE 434
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2415
Practice Address - Country:US
Practice Address - Phone:318-631-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician