Provider Demographics
NPI:1124877436
Name:WILSON, CHARNA
Entity type:Individual
Prefix:
First Name:CHARNA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276 UPPER RIVERDALE RD APT 3B
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-1039
Mailing Address - Country:US
Mailing Address - Phone:804-824-7829
Mailing Address - Fax:
Practice Address - Street 1:610 KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:SCOTTDALE
Practice Address - State:GA
Practice Address - Zip Code:30079-1124
Practice Address - Country:US
Practice Address - Phone:470-242-1341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist