Basic Information
| Provider Information | |||||||||
| NPI: | 1174954432 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | RODNEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5183 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393025183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017034282 | ||||||||
| FaxNumber: | 6017034597 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 12TH ST | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393014158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017034366 | ||||||||
| FaxNumber: | 6017034064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2013 | ||||||||
| LastUpdateDate: | 12/03/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 1972 | AL | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 54949 | MS | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 00579380 | 05 | MS | MEDICAID |