Provider Demographics
NPI:1184040800
Name:WILSON, DAVID CHARLES (LPC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:CHARLES
Last Name:WILSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 DUMAINE PL
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-9234
Mailing Address - Country:US
Mailing Address - Phone:662-378-7888
Mailing Address - Fax:601-853-2990
Practice Address - Street 1:116 DUMAINE PL
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-9234
Practice Address - Country:US
Practice Address - Phone:662-378-7888
Practice Address - Fax:601-853-2990
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-06
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0256101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional