Provider Demographics
NPI:1649612854
Name:WILSON, NICOLAS RAY (PSYD)
Entity type:Individual
Prefix:DR
First Name:NICOLAS
Middle Name:RAY
Last Name:WILSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1695 KERNERSVILLE MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-7159
Mailing Address - Country:US
Mailing Address - Phone:336-515-5000
Mailing Address - Fax:
Practice Address - Street 1:1695 KERNERSVILLE MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-7159
Practice Address - Country:US
Practice Address - Phone:336-515-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-29
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA083766103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical