Provider Demographics
NPI:1720116791
Name:WILSON, WAYNE DOUGLAS (DMIN)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:DOUGLAS
Last Name:WILSON
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 184
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-0184
Mailing Address - Country:US
Mailing Address - Phone:704-871-1712
Mailing Address - Fax:704-871-9354
Practice Address - Street 1:351 TURNERSBURG HWY
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-2798
Practice Address - Country:US
Practice Address - Phone:704-871-1712
Practice Address - Fax:704-871-9354
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3158101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC88903OtherMEDCOST
NC1163NOtherBCBS