Provider Demographics
NPI:1730541368
Name:WILSON, ANTIGONE (LCASA)
Entity type:Individual
Prefix:
First Name:ANTIGONE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 COURT DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2140
Mailing Address - Country:US
Mailing Address - Phone:704-884-2060
Mailing Address - Fax:704-854-4860
Practice Address - Street 1:2505 COURT DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2140
Practice Address - Country:US
Practice Address - Phone:704-884-2060
Practice Address - Fax:704-854-4860
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-23
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21258101YA0400X
NCLCASA21258251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCLCASA21258OtherNORTH CAROLINA SUBSTANCE ABUSE BOARD