Provider Demographics
NPI:1528127594
Name:WILSON, ANTOINETTE DION (LCSW)
Entity type:Individual
Prefix:MS
First Name:ANTOINETTE
Middle Name:DION
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:ANTOINETTE
Other - Middle Name:WILSON
Other - Last Name:GAINEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2010 HIDDEN CT
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-1945
Mailing Address - Country:US
Mailing Address - Phone:229-225-8855
Mailing Address - Fax:
Practice Address - Street 1:2010 HIDDEN CT
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-1945
Practice Address - Country:US
Practice Address - Phone:229-225-8855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2023-09-06
Deactivation Date:2017-12-22
Deactivation Code:
Reactivation Date:2018-10-31
Provider Licenses
StateLicense IDTaxonomies
171M00000X
GACSW0062871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018214Medicaid