Provider Demographics
NPI:1548696388
Name:WILSON, TINA ANDREA (LCAS-A)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:ANDREA
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8430 UNIVERSITY EXEC PARK DR
Mailing Address - Street 2:STE. 655
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-1350
Mailing Address - Country:US
Mailing Address - Phone:704-596-5553
Mailing Address - Fax:704-596-1556
Practice Address - Street 1:8430 UNIVERSITY EXEC PARK DR
Practice Address - Street 2:STE. 655
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-1350
Practice Address - Country:US
Practice Address - Phone:704-596-5553
Practice Address - Fax:704-596-1556
Is Sole Proprietor?:No
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3496A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)