Provider Demographics
NPI:1720619414
Name:WILSON, REGINALD CALVERT JR
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:CALVERT
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 CALLOWAY DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-4008
Mailing Address - Country:US
Mailing Address - Phone:919-412-2662
Mailing Address - Fax:
Practice Address - Street 1:1502 W NC HIGHWAY 54 STE 403
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-5599
Practice Address - Country:US
Practice Address - Phone:919-418-1718
Practice Address - Fax:919-794-5715
Is Sole Proprietor?:No
Enumeration Date:2020-01-31
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NCP0137521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)