Provider Demographics
NPI:1538605704
Name:WILSON, ANDRE (BS)
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9017 MORAY DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-5127
Mailing Address - Country:US
Mailing Address - Phone:318-218-0761
Mailing Address - Fax:
Practice Address - Street 1:9017 MORAY DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-5127
Practice Address - Country:US
Practice Address - Phone:318-218-0761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health