Basic Information
| Provider Information | |||||||||
| NPI: | 1053638759 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | CHERRELLE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MHPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1014 AUTUMN RD | ||||||||
| Address2: | STE 3 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722113704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012211941 | ||||||||
| FaxNumber: | 5012211553 | ||||||||
| Practice Location | |||||||||
| Address1: | 1014 AUTUMN RD | ||||||||
| Address2: | STE 3 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722113704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012211941 | ||||||||
| FaxNumber: | 5012211553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2010 | ||||||||
| LastUpdateDate: | 04/21/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.