Basic Information
| Provider Information | |||||||||
| NPI: | 1093198715 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | SHONDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 COMMERCE PLAZA CIR | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283727386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105212900 | ||||||||
| FaxNumber: | 9107759165 | ||||||||
| Practice Location | |||||||||
| Address1: | 402 N PINE ST | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283585563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107391666 | ||||||||
| FaxNumber: | 9107396822 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2015 | ||||||||
| LastUpdateDate: | 07/21/2016 | ||||||||
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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 | 1041C0700X | P009721 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 04061981 | 05 | NC | MEDICAID |