Provider Demographics
NPI:1588717128
Name:WILSON, MELISSA DIANE (LCSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:DIANE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 OLEANDER DR
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6846
Mailing Address - Country:US
Mailing Address - Phone:910-392-5889
Mailing Address - Fax:910-392-6869
Practice Address - Street 1:4000 OLEANDER DR
Practice Address - Street 2:SUITE 2A
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6846
Practice Address - Country:US
Practice Address - Phone:910-392-5889
Practice Address - Fax:910-392-6869
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0039391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC130PPOtherBLUECROSS BLUESHIELD
NC6002471Medicaid
NC6002471Medicaid