Provider Demographics
NPI:1508195504
Name:JOHN W. WILSON, PSYD, LLC
Entity Type:Organization
Organization Name:JOHN W. WILSON, PSYD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:PSYD
Authorized Official - Phone:404-246-1257
Mailing Address - Street 1:1815 ANNWICKS DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5407
Mailing Address - Country:US
Mailing Address - Phone:404-246-1257
Mailing Address - Fax:
Practice Address - Street 1:3115 ROSWELL RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-7605
Practice Address - Country:US
Practice Address - Phone:404-246-1257
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-22
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003201251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health