Basic Information
Provider Information | |||||||||
NPI: | 1801098686 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILSON | ||||||||
FirstName: | LUCINDA | ||||||||
MiddleName: | GALLANT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | B.S. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GALLANT | ||||||||
OtherFirstName: | HELEN | ||||||||
OtherMiddleName: | LUCINDA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | B.S. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2409 HOMER CLAYTON DR | ||||||||
Address2: |   | ||||||||
City: | GUNTERSVILLE | ||||||||
State: | AL | ||||||||
PostalCode: | 359762207 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2565823203 | ||||||||
FaxNumber: | 2535823216 | ||||||||
Practice Location | |||||||||
Address1: | 2409 HOMER CLAYTON DR | ||||||||
Address2: |   | ||||||||
City: | GUNTERSVILLE | ||||||||
State: | AL | ||||||||
PostalCode: | 359762207 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2565823203 | ||||||||
FaxNumber: | 2535823216 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/04/2007 | ||||||||
LastUpdateDate: | 04/24/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
No ID Information.