Provider Demographics
NPI:1902241045
Name:WILSON, CASSIDY (LAC)
Entity Type:Individual
Prefix:
First Name:CASSIDY
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 BARCELONA WAY
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71909-3359
Mailing Address - Country:US
Mailing Address - Phone:501-420-3777
Mailing Address - Fax:
Practice Address - Street 1:1615 MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-2233
Practice Address - Country:US
Practice Address - Phone:501-332-5236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2106008101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health