Provider Demographics
NPI:1356603682
Name:WILSON, JOHN WAYNE (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WAYNE
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4317 DOGWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-6234
Mailing Address - Country:US
Mailing Address - Phone:404-585-7375
Mailing Address - Fax:
Practice Address - Street 1:1244 CLAIRMONT RD
Practice Address - Street 2:218
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1259
Practice Address - Country:US
Practice Address - Phone:404-585-7375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006696101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional