Provider Demographics
NPI:1043688716
Name:WILSON, ANDREW
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:ANDREW
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW BACS
Mailing Address - Street 1:9817 HADRIANS WAY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-4843
Mailing Address - Country:US
Mailing Address - Phone:318-458-5158
Mailing Address - Fax:318-220-8108
Practice Address - Street 1:6007 FINANCIAL PLZ STE 213
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-2638
Practice Address - Country:US
Practice Address - Phone:318-458-5158
Practice Address - Fax:318-220-8108
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-11
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA86601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical