Provider Demographics
NPI:1679907984
Name:WILSON, BRYAN (EDS, NCSP)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:EDS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 FAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-1219
Mailing Address - Country:US
Mailing Address - Phone:304-574-1176
Mailing Address - Fax:304-574-4109
Practice Address - Street 1:111 FAYETTE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-1219
Practice Address - Country:US
Practice Address - Phone:304-574-1176
Practice Address - Fax:304-574-4109
Is Sole Proprietor?:No
Enumeration Date:2013-08-23
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVN3R136200287103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool