Provider Demographics
NPI:1710026729
Name:WILSON, ERNEST DANIEL
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:DANIEL
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 STUCAWA DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-6516
Mailing Address - Country:US
Mailing Address - Phone:803-561-0345
Mailing Address - Fax:
Practice Address - Street 1:1800 COLONIAL DR
Practice Address - Street 2:IMPACT
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6827
Practice Address - Country:US
Practice Address - Phone:803-898-8133
Practice Address - Fax:803-898-2194
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health