Provider Demographics
NPI:1932235835
Name:WILSON, CATHY LEE (MSW)
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:LEE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 571097
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-1097
Mailing Address - Country:US
Mailing Address - Phone:336-716-0851
Mailing Address - Fax:336-716-0822
Practice Address - Street 1:403 SOUTH HAWTHORNE RD.
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-1097
Practice Address - Country:US
Practice Address - Phone:336-716-0851
Practice Address - Fax:336-716-0822
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0004051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106085Medicaid
NC141EPOtherBCBS
NCB2046OtherMEDCOST
NCB2046OtherMEDCOST