Provider Demographics
NPI:1396171203
Name:WILSON, ISAAC (BACHELOR LEVEL)
Entity type:Individual
Prefix:
First Name:ISAAC
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:BACHELOR LEVEL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 SAINT ANTHONY AVE APT B
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-2993
Mailing Address - Country:US
Mailing Address - Phone:803-297-6744
Mailing Address - Fax:
Practice Address - Street 1:1521 SAINT ANTHONY AVE APT B
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-2993
Practice Address - Country:US
Practice Address - Phone:803-297-6744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-24
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health