Provider Demographics
NPI:1417587932
Name:WILSON, DOTTIE (CDCA174182)
Entity Type:Individual
Prefix:
First Name:DOTTIE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:CDCA174182
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2117 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-2538
Mailing Address - Country:US
Mailing Address - Phone:606-442-7044
Mailing Address - Fax:866-475-7263
Practice Address - Street 1:2903 S 5TH ST
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-2866
Practice Address - Country:US
Practice Address - Phone:740-646-6640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.174182101YA0400X
171M00000X, 175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator