Provider Demographics
NPI:1912022914
Name:WILSON, GARY KEITH (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:KEITH
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17856
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37217-0856
Mailing Address - Country:US
Mailing Address - Phone:615-782-1490
Mailing Address - Fax:615-361-1102
Practice Address - Street 1:510 E IRIS DR
Practice Address - Street 2:SUITE B
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37204-3110
Practice Address - Country:US
Practice Address - Phone:615-782-1490
Practice Address - Fax:615-361-1102
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000000745103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3682700Medicare ID - Type Unspecified