Provider Demographics
NPI:1891955274
Name:WILSON, DEANA L S (PSYD)
Entity Type:Individual
Prefix:
First Name:DEANA
Middle Name:L S
Last Name:WILSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:DEANA
Other - Middle Name:L S
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:JOHNSON
Mailing Address - Street 1:PO BOX 766
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-0766
Mailing Address - Country:US
Mailing Address - Phone:414-303-5465
Mailing Address - Fax:414-310-7496
Practice Address - Street 1:420 E QUAIL RUN
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-5792
Practice Address - Country:US
Practice Address - Phone:414-303-5465
Practice Address - Fax:414-310-7496
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4085101YP2500X
WI2920-57103TC0700X
WI2920103TH0004X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43744000Medicaid