Provider Demographics
NPI:1760822381
Name:WILSON, DAVID LEROY (LMFT, MDIV)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEROY
Last Name:WILSON
Suffix:
Gender:M
Credentials:LMFT, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 N BARDSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT WASHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40047-7602
Mailing Address - Country:US
Mailing Address - Phone:502-822-6861
Mailing Address - Fax:
Practice Address - Street 1:975 N BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:MOUNT WASHINGTON
Practice Address - State:KY
Practice Address - Zip Code:40047-7602
Practice Address - Country:US
Practice Address - Phone:502-822-6861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN101Y00000X
KY2012-012106H00000X
KY167720106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor