Provider Demographics
NPI:1619430444
Name:WILSON, DAVA R (CSW)
Entity Type:Individual
Prefix:
First Name:DAVA
Middle Name:R
Last Name:WILSON
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:DAVA
Other - Middle Name:
Other - Last Name:WHITAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10100 ELIDA RD
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-9058
Mailing Address - Country:US
Mailing Address - Phone:419-695-8010
Mailing Address - Fax:419-695-0004
Practice Address - Street 1:1143 FAIRWAY ST STE 320
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-2452
Practice Address - Country:US
Practice Address - Phone:270-904-6307
Practice Address - Fax:270-904-6314
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2538611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical