Provider Demographics
NPI:1548576903
Name:WILSON, DONNA JANE (LCSW)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:JANE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 PICARDY CT
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-3132
Mailing Address - Country:US
Mailing Address - Phone:270-872-6213
Mailing Address - Fax:
Practice Address - Street 1:321 W STEPHEN FOSTER AVE
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-1419
Practice Address - Country:US
Practice Address - Phone:270-872-6213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100315100Medicaid