Provider Demographics
NPI:1932249133
Name:WILSON PSYCHIATRIC ASSOCIATES, P.L.L.C.
Entity Type:Organization
Organization Name:WILSON PSYCHIATRIC ASSOCIATES, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:G
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-237-8403
Mailing Address - Street 1:2401 WOOTEN BLVD SW STE J
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-4464
Mailing Address - Country:US
Mailing Address - Phone:252-237-8403
Mailing Address - Fax:252-237-7443
Practice Address - Street 1:2401 WOOTEN BLVD SW STE J
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4464
Practice Address - Country:US
Practice Address - Phone:252-237-8403
Practice Address - Fax:252-237-7443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20001292174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89015V1Medicaid
NC89015V1Medicaid
NC2330406Medicare ID - Type Unspecified