Basic Information
| Provider Information | |||||||||
| NPI: | 1205011327 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | MARC | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1425 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WALNUT RIDGE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724761431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708865303 | ||||||||
| FaxNumber: | 8708867002 | ||||||||
| Practice Location | |||||||||
| Address1: | 1815 PLEASANT GROVE RD | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709336886 | ||||||||
| FaxNumber: | 8709339395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2008 | ||||||||
| LastUpdateDate: | 07/09/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2210-C | AR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 5A755 | 01 | AR | BCBS | OTHER | 174440795 | 05 | AR | MEDICAID |