Provider Demographics
NPI:1770041592
Name:WILSON, JOHNNIE LEFUEL IV (LCASA)
Entity Type:Individual
Prefix:MR
First Name:JOHNNIE
Middle Name:LEFUEL
Last Name:WILSON
Suffix:IV
Gender:M
Credentials:LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6307 MELODY LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-5554
Mailing Address - Country:US
Mailing Address - Phone:910-627-7210
Mailing Address - Fax:
Practice Address - Street 1:6307 MELODY LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-5554
Practice Address - Country:US
Practice Address - Phone:910-627-7210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA25300101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)