Individual
IRA WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1799 STUMPF BLVD BLDG 3, TERRYTOWN, LA 70056-3950
(504) 339-5064
Mailing address
448 FAIRFIELD AVE, GRETNA, LA 70056-7034
(504) 339-5064
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
1881067312
LA
Other
Enumeration date
02/14/2017
Last updated
02/14/2017
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