Provider Demographics
NPI:1699221945
Name:WILSON, DEWIGHT EDWIN (RADT1)
Entity Type:Individual
Prefix:MR
First Name:DEWIGHT
Middle Name:EDWIN
Last Name:WILSON
Suffix:
Gender:M
Credentials:RADT1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 PENNSYLVANIA ST.
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590
Mailing Address - Country:US
Mailing Address - Phone:707-643-2715
Mailing Address - Fax:707-643-8536
Practice Address - Street 1:419 PENNSYLVANIA ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-6933
Practice Address - Country:US
Practice Address - Phone:707-643-2715
Practice Address - Fax:707-643-8536
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11966101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)