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Individual

STACY NATASHA WILSON

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
F
Credential
PSY.D., LCAS, MAC

Contact information

Practice address
145 PARKER FISHERY RD, WINTON, NC 27986-9763
(252) 358-5200
Mailing address
1014 ISLAND PARK CIR, SUFFOLK, VA 23435-3275

Taxonomy

Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
LCAS-3290
NC
103T00000X
Psychologist
4371
NC

Other

Enumeration date
02/14/2019
Last updated
02/14/2019
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