| Doctor Name: | MRS. DEMECKA WILSON |
| NPI Number: | 1114388568 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | |
| Business Practice Address: | 1138 Puffer Rd Fayette, MS - 390695133 |
| Business Phone Number: | 6014722310 |
| Business Fax Number: | |
| Mailing Address: | 1644 B Carter Street Suite 2, VIDALIA |
| State: | LA |
| Postal Code: | 71373 |
| Phone Number: | 3184143065 |
| Fax Number: | 3184143067 |
| NPI Enumeration Date: | 03/14/2016 |
| NPI Last Update Date: | 03/14/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |