Basic Information
| Provider Information | |||||||||
| NPI: | 1508086935 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | CANDICE | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 51 WILLOWIND LN | ||||||||
| Address2: | |||||||||
| City: | RINGGOLD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307363281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236821453 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 SHUGART RD | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062705100 | ||||||||
| FaxNumber: | 7062705066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 09/13/2018 | ||||||||
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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 | 101YP2500X | 010346 | GA | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.