Provider Demographics
NPI:1942421169
Name:WILSON, DWIGHT (MS LCAC MAC)
Entity Type:Individual
Prefix:MR
First Name:DWIGHT
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:MS LCAC MAC
Other - Prefix:MR
Other - First Name:DWIGHT
Other - Middle Name:W
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, MAC, LCAC, ICA
Mailing Address - Street 1:1810 BROAD RIPPLE AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-2363
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1810 BROAD RIPPLE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-2363
Practice Address - Country:US
Practice Address - Phone:317-251-8550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional