Provider Demographics
NPI:1831943489
Name:WILSON, TYHESSA (LCASA)
Entity type:Individual
Prefix:
First Name:TYHESSA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 MARTIN LUTHER KING JR DR
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-5443
Mailing Address - Country:US
Mailing Address - Phone:910-370-0018
Mailing Address - Fax:919-820-8551
Practice Address - Street 1:511 MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-5443
Practice Address - Country:US
Practice Address - Phone:910-370-0018
Practice Address - Fax:919-820-8551
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27039101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)