Individual
MARY WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
10710 OLD HIGHWAY 64, BOLIVAR, TN 38008-3587
(731) 658-6113
(731) 658-6165
Mailing address
700 LOCUST ST, BOLIVAR, TN 38008-2858
(731) 658-6113
(731) 658-6165
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
57436800
—
TN
Enumeration date
09/22/2006
Last updated
07/09/2007
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