Provider Demographics
NPI:1952704686
Name:WILSON, DAWN A (MS)
Entity Type:Individual
Prefix:MS
First Name:DAWN
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS
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 52
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:FL
Mailing Address - Zip Code:32702-0052
Mailing Address - Country:US
Mailing Address - Phone:352-478-5741
Mailing Address - Fax:
Practice Address - Street 1:42141 W LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:FL
Practice Address - Zip Code:32702-9508
Practice Address - Country:US
Practice Address - Phone:352-478-5741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-08
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X
FL134255101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171W00000XOther Service ProvidersContractor