Provider Demographics
NPI:1558305359
Name:WILSON, BRIAN ANDREW (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:ANDREW
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17401 COMMERCE PARK BLVD STE 103-0319
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3501
Mailing Address - Country:US
Mailing Address - Phone:727-239-5684
Mailing Address - Fax:
Practice Address - Street 1:16203 HAMPTON TRACE CT
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2745
Practice Address - Country:US
Practice Address - Phone:727-239-5684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2021-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8981103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical