Provider Demographics
NPI:1528413952
Name:WILSON, NATHANIEL JR
Entity Type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 APEX LANDING WAY APT 102
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-4644
Mailing Address - Country:US
Mailing Address - Phone:704-840-5530
Mailing Address - Fax:704-595-3120
Practice Address - Street 1:2325 APEX LANDING WAY APT 102
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-4644
Practice Address - Country:US
Practice Address - Phone:704-840-5530
Practice Address - Fax:704-595-3120
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-04
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YA0400X, 1041C0700X
NCLCAS-22744101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical