Basic Information
| Provider Information | |||||||||
| NPI: | 1922034008 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ANDERKO | ||||||||
| OtherFirstName: | PATRICIA | ||||||||
| OtherMiddleName: | D. | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1305 S CANNON BLVD | ||||||||
| Address2: | |||||||||
| City: | KANNAPOLIS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280836232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049391184 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1309 S CANNON BLVD | ||||||||
| Address2: | |||||||||
| City: | KANNAPOLIS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280836232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049333212 | ||||||||
| FaxNumber: | 7049333221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 03/11/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C003790 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6106653 | 05 | NC | MEDICAID | 146FK | 01 | NC | BCBS | OTHER |