Provider Demographics
NPI:1023678539
Name:WILSON, CHESTER JR (EDD, CAP, CMHP)
Entity type:Individual
Prefix:DR
First Name:CHESTER
Middle Name:
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:EDD, CAP, CMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 N FREDERICK AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-3400
Mailing Address - Country:US
Mailing Address - Phone:386-675-0098
Mailing Address - Fax:
Practice Address - Street 1:240 N FREDERICK AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-3400
Practice Address - Country:US
Practice Address - Phone:386-675-0098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4318101YA0400X
FL50334101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4318OtherCERTIFIED ADDICTION PROFESSIONAL
FL50334OtherCERTIFIED MENTAL HEALTH PROFESSIONAL