Provider Demographics
NPI:1245806439
Name:WILSON, WILLIE J JR (CAC-AD)
Entity Type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:J
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:CAC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3916 ANNELLEN RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-7215
Mailing Address - Country:US
Mailing Address - Phone:443-271-2874
Mailing Address - Fax:
Practice Address - Street 1:3111 CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-2734
Practice Address - Country:US
Practice Address - Phone:443-271-2874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC-1150101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)