Basic Information
| Provider Information | |||||||||
| NPI: | 1558661819 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLAY WILSON & ASSOCIATES | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | THE COGNITIVE CONNECTION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1109 2ND AVE SW | ||||||||
| Address2: | |||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286022545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283276026 | ||||||||
| FaxNumber: | 8283278796 | ||||||||
| Practice Location | |||||||||
| Address1: | 1109 2ND AVE SW | ||||||||
| Address2: | |||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286022545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283276026 | ||||||||
| FaxNumber: | 8283278796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2010 | ||||||||
| LastUpdateDate: | 11/02/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HERRON | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL RECORDS SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 8283276026 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 6005415 | 05 | NC | MEDICAID |