1205249430 NPI number — MR. GREGORY ALVIN WILSON SR. LMSW

Table of content: MR. GREGORY ALVIN WILSON SR. LMSW (NPI 1205249430)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205249430 NPI number — MR. GREGORY ALVIN WILSON SR. LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
GREGORY
Provider Middle Name:
ALVIN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
SR.
Provider Credential Text:
LMSW
Provider Gender Code:
M

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:
1205249430
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
151 MEDGAR EVERS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAMBLING
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71245-3211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5500 ARMSTRONG ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATTLE CREEK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-223-6907
Provider Business Practice Location Address Fax Number:
269-223-6907
Provider Enumeration Date:
06/05/2014

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: 171000000X , with the licence number:  9259 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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