Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YP1600X | Pastoral Counselor | ||
Y | 103K00000X | Behavior Analyst |
NPI | 1215339015 |
---|---|
Provider Name | Danice Wilson |
First Address | Austell, GA 30106-8535 |
Second Address | Austell, GA 30106-8535 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/09/2014 |
Last Update Date | 23/09/2014 |