Provider Demographics
NPI:1972346146
Name:WILSON, TICOYIA M
Entity type:Individual
Prefix:
First Name:TICOYIA
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 SUPERIOR DR
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:NC
Mailing Address - Zip Code:28390-3190
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1477 NC 24-87
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:NC
Practice Address - Zip Code:28326-6752
Practice Address - Country:US
Practice Address - Phone:910-218-1602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRBT-24-353684106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician