Provider Demographics
NPI:1306983002
Name:WILSON, HEATHER L (MHA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 WITT MARSH RD
Mailing Address - Street 2:
Mailing Address - City:GAMALIEL
Mailing Address - State:KY
Mailing Address - Zip Code:42140-9533
Mailing Address - Country:US
Mailing Address - Phone:270-901-5000
Mailing Address - Fax:270-842-5268
Practice Address - Street 1:201 E 2ND ST
Practice Address - Street 2:
Practice Address - City:TOMPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42167-1673
Practice Address - Country:US
Practice Address - Phone:270-487-5655
Practice Address - Fax:270-487-5948
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30604011Medicaid