Provider Demographics
NPI:1013201292
Name:WILSON, DALLAS RANDALL (MSW, LSW)
Entity Type:Individual
Prefix:MR
First Name:DALLAS
Middle Name:RANDALL
Last Name:WILSON
Suffix:
Gender:M
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 N TILLOTSON AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-3988
Mailing Address - Country:US
Mailing Address - Phone:765-288-1928
Mailing Address - Fax:765-741-0335
Practice Address - Street 1:16 SW 5TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-4101
Practice Address - Country:US
Practice Address - Phone:765-288-1928
Practice Address - Fax:765-935-1582
Is Sole Proprietor?:No
Enumeration Date:2011-06-05
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health