Provider Demographics
NPI:1194837500
Name:WILSON, EDWARD S III (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:S
Last Name:WILSON
Suffix:III
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 SAVANNAH RD
Mailing Address - Street 2:
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958
Mailing Address - Country:US
Mailing Address - Phone:302-448-4266
Mailing Address - Fax:302-448-4193
Practice Address - Street 1:1518 SAVANNAH RD
Practice Address - Street 2:
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958
Practice Address - Country:US
Practice Address - Phone:302-448-4266
Practice Address - Fax:302-448-4193
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB10000183103T00000X
DEB1-0000183103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE510402460OtherEIN#