Provider Demographics
NPI:1093844839
Name:WILSON, DWAYNE CHARLES
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:CHARLES
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93302-1000
Mailing Address - Country:US
Mailing Address - Phone:661-868-6138
Mailing Address - Fax:661-868-6133
Practice Address - Street 1:1401 L ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-4522
Practice Address - Country:US
Practice Address - Phone:661-868-6138
Practice Address - Fax:661-868-6133
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CAW1008111331101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator