1033256938 NPI number — TRACY C WILSON M.ED.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033256938 NPI number — TRACY C WILSON M.ED.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
TRACY
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.ED.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033256938
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 BRADLEY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARROLLTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30117-3217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-832-9140
Provider Business Mailing Address Fax Number:
770-832-3046

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 BRADLEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARROLLTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30117-3217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-832-9140
Provider Business Practice Location Address Fax Number:
770-832-3046
Provider Enumeration Date:
01/31/2007

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: 101YP2500X , with the licence number:  2748 , 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: 844101180A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11643300 . This is a "CAQH" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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