Provider Demographics
NPI:1699147926
Name:WILSON, ROXIE (RSW)
Entity type:Individual
Prefix:MISS
First Name:ROXIE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:RSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8946 INTERLINE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-1913
Mailing Address - Country:US
Mailing Address - Phone:225-615-7282
Mailing Address - Fax:
Practice Address - Street 1:8946 INTERLINE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-1913
Practice Address - Country:US
Practice Address - Phone:225-615-7282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA008784269103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst