Provider Demographics
NPI:1912921743
Name:WILSON, MIA R (EDD)
Entity Type:Individual
Prefix:DR
First Name:MIA
Middle Name:R
Last Name:WILSON
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 8056
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211
Mailing Address - Country:US
Mailing Address - Phone:904-891-6614
Mailing Address - Fax:904-378-9922
Practice Address - Street 1:5379 LENOX AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-4737
Practice Address - Country:US
Practice Address - Phone:904-891-6614
Practice Address - Fax:904-378-9922
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2014-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2435101YA0400X
FLMH8078101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)