Basic Information
| Provider Information | |||||||||
| NPI: | 1609396233 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | FREDRICK | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5 | ||||||||
| Address2: | |||||||||
| City: | RODESSA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710690005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182234665 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4601 N MARKET ST | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711072971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184248735 | ||||||||
| FaxNumber: | 3184248739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.