Basic Information
| Provider Information | |||||||||
| NPI: | 1932249133 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WILSON PSYCHIATRIC ASSOCIATES, P.L.L.C. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 WOOTEN BLVD SW STE J | ||||||||
| Address2: | |||||||||
| City: | WILSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278934464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522378403 | ||||||||
| FaxNumber: | 2522377443 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 WOOTEN BLVD SW STE J | ||||||||
| Address2: | |||||||||
| City: | WILSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278934464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522378403 | ||||||||
| FaxNumber: | 2522377443 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | JENNY | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2522378403 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 20001292 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 89015V1 | 05 | NC | MEDICAID |