Provider Demographics
NPI:1982704482
Name:WILEMON, CARLA JO (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:JO
Last Name:WILEMON
Suffix:
Gender:F
Credentials:LMSW
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 764
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MS
Mailing Address - Zip Code:38843-0764
Mailing Address - Country:US
Mailing Address - Phone:662-862-3453
Mailing Address - Fax:
Practice Address - Street 1:2434 S EASON BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-6942
Practice Address - Country:US
Practice Address - Phone:662-844-1717
Practice Address - Fax:662-680-6416
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MSM7451104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health