Provider Demographics
NPI:1871630178
Name:WILSON, SHIRLEY ANN (PHD)
Entity type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7165 B SWINNEA
Mailing Address - Street 2:STE 1
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671
Mailing Address - Country:US
Mailing Address - Phone:662-349-6658
Mailing Address - Fax:662-349-6856
Practice Address - Street 1:7165 B SWINNEA
Practice Address - Street 2:STE 1
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671
Practice Address - Country:US
Practice Address - Phone:662-349-6658
Practice Address - Fax:662-349-6856
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS103T00000X, 103TB0200X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent