Provider Demographics
NPI:1578802310
Name:WILSON, GREGORY LEE (M ED)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:LEE
Last Name:WILSON
Suffix:
Gender:M
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50209
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-0021
Mailing Address - Country:US
Mailing Address - Phone:864-227-1001
Mailing Address - Fax:864-227-3619
Practice Address - Street 1:1612 RIVERS ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29649-8513
Practice Address - Country:US
Practice Address - Phone:864-227-1001
Practice Address - Fax:864-227-3619
Is Sole Proprietor?:No
Enumeration Date:2013-02-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13011718101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)