Individual
TINA WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
139 WHIPPOORWILL LN, MT HOLLY, NC 28120-9761
(704) 574-1549
Mailing address
205 WHIPPOORWILL LN, MT HOLLY, NC 28120-9761
(704) 574-1549
Taxonomy
Speciality
Code
Description
License number
State
320800000X
Mental Illness Community Based Residential Treatment Facility
Primary
MHL-036-323
NC
Other
Enumeration date
12/14/2016
Last updated
08/10/2017
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