Provider Demographics
NPI:1770560401
Name:WILSON, SUSAN ANNETTE (MED)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ANNETTE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1733 BONNYCASTLE AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-1014
Mailing Address - Country:US
Mailing Address - Phone:502-417-9881
Mailing Address - Fax:
Practice Address - Street 1:3715 BARDSTOWN ROAD, SUITE 415
Practice Address - Street 2:FAMILY LINKS
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218
Practice Address - Country:US
Practice Address - Phone:502-639-0152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-23
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-1002101YA0400X
KYKY-0488103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)