Provider Demographics
NPI:1841848033
Name:WILTON, ALEXA
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:
Last Name:WILTON
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 1:224 RICE ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-2053
Mailing Address - Country:US
Mailing Address - Phone:814-598-3285
Mailing Address - Fax:
Practice Address - Street 1:405 PETTIGRU STREET
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-4081
Practice Address - Country:US
Practice Address - Phone:814-598-3285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-30
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12181101YP2500X
SC160621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3335OtherMEDICARE
SC421504Medicaid