Provider Demographics
NPI:1356059844
Name:WILSON, JUAN (LCSW, LCAC)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:LCSW, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 DIAMOND LN
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-8320
Mailing Address - Country:US
Mailing Address - Phone:765-918-3923
Mailing Address - Fax:
Practice Address - Street 1:9623 WINDERMERE BLVD
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9180
Practice Address - Country:US
Practice Address - Phone:888-416-4646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-14
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34010348A1041C0700X
IN87001672A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty