1528127594 NPI number — MS. ANTOINETTE DION WILSON LCSW

Table of content: MS. ANTOINETTE DION WILSON LCSW (NPI 1528127594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528127594 NPI number — MS. ANTOINETTE DION WILSON LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
ANTOINETTE
Provider Middle Name:
DION
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GAINEY
Provider Other First Name:
ANTOINETTE
Provider Other Middle Name:
WILSON
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1528127594
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
12/22/2017
NPI Reactivation Date:
10/31/2018

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2010 HIDDEN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31707-1945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-225-8855
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2010 HIDDEN CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31707-1945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-225-8855
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: CSW006287 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00018214 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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