Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YP1600X | Pastoral Counselor |
NPI | 1083276497 |
---|---|
Provider Name | Nina Wilson |
First Address | Stockbridge, GA 30281-0035 |
Second Address | Louisville, KY 40203-3207 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/07/2019 |
Last Update Date | 05/07/2019 |