Provider Demographics
NPI:1992213573
Name:WILSON, ALVIN JODY (LCDCIII)
Entity Type:Individual
Prefix:
First Name:ALVIN
Middle Name:JODY
Last Name:WILSON
Suffix:
Gender:M
Credentials:LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:382 S MCARTHUR ST
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-3627
Mailing Address - Country:US
Mailing Address - Phone:740-702-2200
Mailing Address - Fax:740-702-2202
Practice Address - Street 1:11402 STATE ROUTE 50
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45617
Practice Address - Country:US
Practice Address - Phone:740-702-2200
Practice Address - Fax:740-702-2202
Is Sole Proprietor?:No
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH141243101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)