Basic Information
| Provider Information | |||||||||
| NPI: | 1114388568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | DEMECKA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1644 B CARTER STREET SUITE 2 | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184143065 | ||||||||
| FaxNumber: | 3184143067 | ||||||||
| Practice Location | |||||||||
| Address1: | 1138 PUFFER RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390695133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014722310 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2016 | ||||||||
| LastUpdateDate: | 07/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | LA | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.