Provider Demographics
NPI:1902327018
Name:WILSON, LAWRENCE EDWARD (NACAII, LADACII,)
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:EDWARD
Last Name:WILSON
Suffix:
Gender:M
Credentials:NACAII, LADACII,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3543 PHILSDALE AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-5450
Mailing Address - Country:US
Mailing Address - Phone:901-277-6101
Mailing Address - Fax:901-729-2933
Practice Address - Street 1:1548 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2432
Practice Address - Country:US
Practice Address - Phone:901-277-6101
Practice Address - Fax:901-729-2933
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA016414101YA0400X
TNLDC0000000344101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)