Provider Demographics
NPI:1346903390
Name:WILSON, DAVID WARREN (MED)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:WARREN
Last Name:WILSON
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 WILLOW GLEN RD
Mailing Address - Street 2:
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348-2119
Mailing Address - Country:US
Mailing Address - Phone:302-345-8815
Mailing Address - Fax:610-388-9518
Practice Address - Street 1:608 WILLOW GLEN RD
Practice Address - Street 2:
Practice Address - City:KENNETT SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19348-2119
Practice Address - Country:US
Practice Address - Phone:302-345-8815
Practice Address - Fax:610-388-9518
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS007970L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist