Provider Demographics
NPI:1982836623
Name:WILSON, DEAN A (PHD,LMFT)
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD,LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 21ST AVE SE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-2827
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3491 GANDY BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-2658
Practice Address - Country:US
Practice Address - Phone:727-547-0607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2365106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist