Provider Demographics
NPI:1679907984
Name:WILSON, BRYAN (EDD, NCSP, BC-TMH)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:EDD, NCSP, BC-TMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1648 GREATHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26187-8400
Mailing Address - Country:US
Mailing Address - Phone:304-550-7523
Mailing Address - Fax:
Practice Address - Street 1:200 PUTNAM ST STE 410
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-3009
Practice Address - Country:US
Practice Address - Phone:740-401-9766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-23
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVN3R136200287103TS0200X
OHSP.00685103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool