Provider Demographics
NPI:1356533137
Name:DENNIS W WILSON PHD PLLC
Entity type:Organization
Organization Name:DENNIS W WILSON PHD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:731-431-0609
Mailing Address - Street 1:728 BLACKMON STREET
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:TN
Mailing Address - Zip Code:38355-6829
Mailing Address - Country:US
Mailing Address - Phone:731-431-0609
Mailing Address - Fax:
Practice Address - Street 1:1020 ELLINGTON DR
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:TN
Practice Address - Zip Code:38358-3150
Practice Address - Country:US
Practice Address - Phone:731-431-0609
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN36815542Medicaid
TN36815542Medicare PIN